Provider Demographics
NPI:1164621801
Name:KOLB, BETHANY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:LYNN
Last Name:KOLB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 BLANCA AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2340
Mailing Address - Country:US
Mailing Address - Phone:719-589-8028
Mailing Address - Fax:719-589-8086
Practice Address - Street 1:106 BLANCA AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2340
Practice Address - Country:US
Practice Address - Phone:719-589-8028
Practice Address - Fax:719-589-8086
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ81984207V00000X
CO49510207V00000X
NMMD2009-0554207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO40282210Medicaid
CO40282210Medicaid