Provider Demographics
NPI:1801854179
Name:COLONNA, JOSEPH GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:GEORGE
Last Name:COLONNA
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 1:11350 PEMBROOKE SQ
Mailing Address - Street 2:SUITE 311
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4809
Mailing Address - Country:US
Mailing Address - Phone:301-645-7011
Mailing Address - Fax:301-645-7964
Practice Address - Street 1:11350 PEMBROOKE SQ
Practice Address - Street 2:SUITE 311
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4809
Practice Address - Country:US
Practice Address - Phone:301-645-7011
Practice Address - Fax:301-645-7964
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD32730208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2406OtherMEDICARE PTAN
MD448000700Medicaid
MD491473Medicare PIN
MD2406OtherMEDICARE PTAN