1770709628 NPI number — CHARLES TRUMAN COLBERT JR. C.S.T./C.F.A.

NPI Number: 1770709628
Health Care Provider/Practitioner: CHARLES TRUMAN COLBERT JR. C.S.T./C.F.A.

NPI Number : 1770709628 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1770709628",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "COLBERT",
    "FirstName": "CHARLES",
    "MiddleName": "TRUMAN",
    "NamePrefix": "MR.",
    "NameSuffix": "JR.",
    "Credential": "C.S.T./C.F.A.",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "334 DYLAN WAY",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "MCDONOUGH",
    "MailingAddressStateName": "GA",
    "MailingAddressPostalCode": "30252-6186",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "770-914-1517",
    "MailingAddressFaxNumber": "770-991-1155",
    "FirstLinePracticeLocationAddress": "6525 PROFESSIONAL PL",
    "SecondLinePracticeLocationAddress": "SUITE A",
    "PracticeLocationAddressCityName": "RIVERDALE",
    "PracticeLocationAddressStateName": "GA",
    "PracticeLocationAddressPostalCode": "30274-2519",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "770-991-1150",
    "PracticeLocationAddressFaxNumber": "770-991-1155",
    "EnumerationDate": "04/18/2007",
    "LastUpdateDate": "03/02/2009",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "246ZS0410X",
          "TaxonomyName": "Surgical Technologist",
          "LicenseNumber": null,
          "LicenseNumberStateCode": null,
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "246ZC0007X",
          "TaxonomyName": "Surgical Assistant",
          "LicenseNumber": null,
          "LicenseNumberStateCode": null,
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}