Provider Demographics
NPI:1922074848
Name:COLBERT, NICKI L (DO)
Entity Type:Individual
Prefix:
First Name:NICKI
Middle Name:L
Last Name:COLBERT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 N GRAHAM ST
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-3100
Mailing Address - Country:US
Mailing Address - Phone:254-965-1171
Mailing Address - Fax:254-965-1174
Practice Address - Street 1:725 N GRAHAM ST
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-3100
Practice Address - Country:US
Practice Address - Phone:254-965-1171
Practice Address - Fax:254-965-1174
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4311207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160759004Medicaid
TXH91251Medicare UPIN
TX160759004Medicaid