Provider Demographics
NPI:1649252396
Name:KOLBECK, PETER (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:KOLBECK
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 1:3637 MISSION AVE
Mailing Address - Street 2:BLDG A STE 5
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-2946
Mailing Address - Country:US
Mailing Address - Phone:916-863-1496
Mailing Address - Fax:
Practice Address - Street 1:3637 MISSION AVE
Practice Address - Street 2:BLDG A STE 5
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-2946
Practice Address - Country:US
Practice Address - Phone:916-863-1496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC88598174400000X
CAG78120207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered174400000XOther Service ProvidersSpecialist
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC88598Medicare UPIN