Provider Demographics
NPI:1982670733
Name:COLVIN, THOMAS L (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:L
Last Name:COLVIN
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 1:2106 LOOP RD STE A
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-3343
Mailing Address - Country:US
Mailing Address - Phone:318-435-6363
Mailing Address - Fax:318-435-4646
Practice Address - Street 1:2106 LOOP RD STE A
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-3343
Practice Address - Country:US
Practice Address - Phone:318-435-6363
Practice Address - Fax:318-435-4646
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.019859207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1449571Medicaid
LAL92021OtherVANTAGE PROVIDER NUMBER
LA4371062OtherAETNA PROVIDER NUMBER
LA1387533Medicaid
LA1449571Medicaid
LA4371062OtherAETNA PROVIDER NUMBER
LAL92021OtherVANTAGE PROVIDER NUMBER
LA55917Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE