Provider Demographics
NPI:1871685982
Name:HALES, COLIN LEONARD (MD)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:LEONARD
Last Name:HALES
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 1:3758 PARK PLAZA CIRCLE
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642
Mailing Address - Country:US
Mailing Address - Phone:409-983-2035
Mailing Address - Fax:409-982-6513
Practice Address - Street 1:3758 PARK PLAZA CIRCLE
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642
Practice Address - Country:US
Practice Address - Phone:409-983-2035
Practice Address - Fax:409-982-6513
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9217207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121390201Medicaid
TX121390201Medicaid
TX00470KMedicare ID - Type Unspecified