Provider Demographics
NPI:1275584237
Name:KOLYBABIUK, YAROSLAW J (MD)
Entity Type:Individual
Prefix:DR
First Name:YAROSLAW
Middle Name:J
Last Name:KOLYBABIUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20091 PASSAGIO DR
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-1977
Mailing Address - Country:US
Mailing Address - Phone:609-828-1100
Mailing Address - Fax:
Practice Address - Street 1:20091 PASSAGIO DR
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-1977
Practice Address - Country:US
Practice Address - Phone:609-828-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME162104207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE13540Medicare UPIN
NJ156503AS7Medicare ID - Type Unspecified