Provider Demographics
NPI:1295727550
Name:COLLIGAN, JOHN LIEBERT (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LIEBERT
Last Name:COLLIGAN
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 1:3203 CYPRIEN LN
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-2254
Mailing Address - Country:US
Mailing Address - Phone:337-478-6361
Mailing Address - Fax:337-474-0628
Practice Address - Street 1:2000 OPELOUSAS ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-2641
Practice Address - Country:US
Practice Address - Phone:337-439-9983
Practice Address - Fax:337-437-9460
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10207207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1121878Medicaid
LAB62805Medicare UPIN
LA4E6876706Medicare PIN