Healthcare Provider Details

I. General information

NPI: 1265401582
Provider Name (Legal Business Name): KEITH A COLOMB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 11/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BEAULLIEU DR. BLDG #5
LAFAYETTE LA
70508-0000
US

IV. Provider business mailing address

200 BEAULLIEU DR. BLDG #5
LAFAYETTE LA
70508-0000
US

V. Phone/Fax

Practice location:
  • Phone: 337-267-4336
  • Fax: 337-267-4167
Mailing address:
  • Phone: 337-267-4336
  • Fax: 337-267-4167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD019858
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: