Basic Information
Provider Information | |||||||||
NPI: | 1811995293 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AITKEN | ||||||||
FirstName: | COLLEEN | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 737 W CHILDS AVE | ||||||||
Address2: |   | ||||||||
City: | MERCED | ||||||||
State: | CA | ||||||||
PostalCode: | 953416805 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2093831848 | ||||||||
FaxNumber: | 2093831296 | ||||||||
Practice Location | |||||||||
Address1: | 301 HOWARD RD | ||||||||
Address2: |   | ||||||||
City: | WESTLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 95387 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2098943141 | ||||||||
FaxNumber: | 2098943082 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2005 | ||||||||
LastUpdateDate: | 11/16/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A68298 | CA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 00A682980 | 01 | CA | BLUE SHIELD OF CA PIN | OTHER | 102109 | 01 | CA | BOARD CERT # | OTHER | BG6588480 | 01 | CA | DEA CERT # | OTHER |