Provider Demographics
NPI:1457414666
Name:KOLBAY, PETER LLOYD (OD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:LLOYD
Last Name:KOLBAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4918 SOMMET DR
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-6353
Mailing Address - Country:US
Mailing Address - Phone:801-273-0204
Mailing Address - Fax:
Practice Address - Street 1:6191 S STATE ST
Practice Address - Street 2:SEARS OPTICAL FASHION PLACE MALL
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7258
Practice Address - Country:US
Practice Address - Phone:801-281-4281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT109787-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist