Provider Demographics
NPI:1700807047
Name:NAWAB, COLLEEN DIETZ (MD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:DIETZ
Last Name:NAWAB
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 1:8709 SUMMIT RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-1378
Mailing Address - Country:US
Mailing Address - Phone:502-742-5110
Mailing Address - Fax:
Practice Address - Street 1:800 ZORN AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-1433
Practice Address - Country:US
Practice Address - Phone:502-287-5105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33955208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYH34837Medicare UPIN