Healthcare Provider Details

I. General information

NPI: 1548248636
Provider Name (Legal Business Name): WONDIFUL A COLBERT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 04/28/2020
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25892 NORTH JAMES MADISON HWY
NEW CANTON VA
23123
US

IV. Provider business mailing address

PO BOX 650859
DALLAS TX
75265-0859
US

V. Phone/Fax

Practice location:
  • Phone: 434-581-3271
  • Fax: 434-581-1105
Mailing address:
  • Phone: 434-581-3271
  • Fax: 434-581-1105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberQ7346
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101236778
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: