Healthcare Provider Details

I. General information

NPI: 1083233720
Provider Name (Legal Business Name): LUC ALEXANDER COLBURN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 N 12TH ST FL 3
PHOENIX AZ
85006-2837
US

IV. Provider business mailing address

1441 N 12TH ST FL 3
PHOENIX AZ
85006-2837
US

V. Phone/Fax

Practice location:
  • Phone: 602-521-5100
  • Fax: 623-707-4243
Mailing address:
  • Phone: 602-521-5100
  • Fax: 623-707-4243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number80319
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number14204666-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number14204666-1205
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number80319
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: