Provider Demographics
NPI:1720158579
Name:COLOMBO, JOHN DOMENICO (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DOMENICO
Last Name:COLOMBO
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 1:3350 GRATIOT BLVD
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040-2121
Mailing Address - Country:US
Mailing Address - Phone:810-364-4000
Mailing Address - Fax:810-364-5995
Practice Address - Street 1:3350 GRATIOT BLVD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-2121
Practice Address - Country:US
Practice Address - Phone:810-364-4000
Practice Address - Fax:810-364-5995
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084357207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I70159Medicare UPIN