Provider Demographics
NPI:1336135276
Name:KOLB, LISA GERETTE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:GERETTE
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 1:1125 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-5227
Mailing Address - Country:US
Mailing Address - Phone:573-634-2620
Mailing Address - Fax:573-634-2033
Practice Address - Street 1:1125 MADISON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5227
Practice Address - Country:US
Practice Address - Phone:573-634-2620
Practice Address - Fax:573-634-2033
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO106050207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO110095712OtherRAILROAD MEDICARE
MO206994907Medicaid
MOF20696Medicare UPIN
MOF20696Medicare UPIN