Provider Demographics
NPI:1174601264
Name:COLBURN, MICHAEL W (DPM)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:COLBURN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 MURRIETA BLVD
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-4111
Mailing Address - Country:US
Mailing Address - Phone:925-455-1555
Mailing Address - Fax:925-292-7592
Practice Address - Street 1:911 MORAGA RD STE 101
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-4591
Practice Address - Country:US
Practice Address - Phone:925-962-9120
Practice Address - Fax:925-962-9122
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2942213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E29420Medicaid
T11525Medicare UPIN
000E29420Medicare ID - Type Unspecified