Provider Demographics
NPI:1326335134
Name:JOHNSON, KOLBY V (MD)
Entity Type:Individual
Prefix:
First Name:KOLBY
Middle Name:V
Last Name:JOHNSON
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 1:465 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4008
Mailing Address - Country:US
Mailing Address - Phone:208-282-4421
Mailing Address - Fax:208-282-4818
Practice Address - Street 1:465 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4008
Practice Address - Country:US
Practice Address - Phone:208-282-4421
Practice Address - Fax:208-282-4818
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMR-1195207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine