Healthcare Provider Details

I. General information

NPI: 1679553853
Provider Name (Legal Business Name): MICHAEL J COLSTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MICHAEL JUDE COLSTON MD

II. Dates (important events)

Enumeration Date: 01/22/2006
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

IV. Provider business mailing address

1613 E HARTFORD AVE
MILWAUKEE WI
53211-3037
US

V. Phone/Fax

Practice location:
  • Phone: 703-776-3814
  • Fax: 703-776-4018
Mailing address:
  • Phone: 847-688-4560
  • Fax: 847-688-2697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101102701
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number0101102701
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: