Healthcare Provider Details

I. General information

NPI: 1629770565
Provider Name (Legal Business Name): CARLA JEAN COLASURDO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 06/21/2026
Certification Date: 06/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1230 BAXTER ST
ATHENS GA
30606-3712
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-2273
  • Fax:
Mailing address:
  • Phone: 706-389-3860
  • Fax: 706-389-3861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: