Provider Demographics
NPI:1578564894
Name:KOLBERG, JOHN JOSEPH (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:KOLBERG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 POST AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-2233
Mailing Address - Country:US
Mailing Address - Phone:516-338-8802
Mailing Address - Fax:516-338-4043
Practice Address - Street 1:265 POST AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-2233
Practice Address - Country:US
Practice Address - Phone:516-338-8802
Practice Address - Fax:516-338-4043
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005450213E00000X, 213EP1101X, 213ES0000X, 213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01882686Medicaid
NYPA5491OtherMEDICARE
NYU71786Medicare UPIN
NY01882686Medicaid