MEDICARE: DAVID J. COLVIN MD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	022840	LA

General Provider Information

NPI Number	:	1831402254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVID J. COLVIN MD LLC

Provider Business Mailing Address
First Line	:	148 WATERS EDGE DR
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71106-7774
Country	:	US
Telephone Number	:	318-797-1687
Fax Number	:

Provider Business Practice Location Address
First Line	:	148 WATERS EDGE DR
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71106-7774
Country	:	US
Telephone Number	:	318-797-1687
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DAVID J COLVIN
Credential	:	M.D.
Telephone Number	:	318-797-1687

Provider Enumeration Date	:	07/15/2010
Last Update Date	:	07/15/2010

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