Provider Demographics
NPI:1710446794
Name:COLFAX, MICHAEL TYRO (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TYRO
Last Name:COLFAX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3278 MITCHELL BLVD
Mailing Address - Street 2:
Mailing Address - City:MOODY AFB
Mailing Address - State:GA
Mailing Address - Zip Code:31699-1500
Mailing Address - Country:US
Mailing Address - Phone:229-257-2784
Mailing Address - Fax:
Practice Address - Street 1:3278 MITCHELL BLVD
Practice Address - Street 2:
Practice Address - City:MOODY AFB
Practice Address - State:GA
Practice Address - Zip Code:31699-3425
Practice Address - Country:US
Practice Address - Phone:229-257-2778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2022-01387207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program