Provider Demographics
NPI:1700839859
Name:COLCLOUGH, JUDITH YEN LIN (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:YEN LIN
Last Name:COLCLOUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2000 PERIMETER PARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-8442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6905 KNIGHTDALE BLVD STE 106
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-6506
Practice Address - Country:US
Practice Address - Phone:919-261-8760
Practice Address - Fax:919-261-8765
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3811207Q00000X
MA237887207Q00000X
NC200401649207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110080968AMedicaid
MA000851002Medicare PIN