Provider Demographics
NPI:1053396341
Name:COLBERG, JOHN W (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:COLBERG
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9805
Mailing Address - Street 2:300 GEORGE ST 6TH FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06536-0805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 HOWARD AVE
Practice Address - Street 2:YALE PHYSICIANS BUILDING 3RD FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1369
Practice Address - Country:US
Practice Address - Phone:203-785-2815
Practice Address - Fax:203-785-4043
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2008-06-25
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Provider Licenses
StateLicense IDTaxonomies
CT036647208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001366477Medicaid
CT34000287Medicare ID - Type Unspecified
CT001366477Medicaid