Provider Demographics
NPI:1780626127
Name:KOLTES, LISA R (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:KOLTES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:315 E ELM ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4857
Mailing Address - Country:US
Mailing Address - Phone:208-459-7415
Mailing Address - Fax:208-453-3200
Practice Address - Street 1:315 E ELM ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4857
Practice Address - Country:US
Practice Address - Phone:208-459-7415
Practice Address - Fax:208-453-3200
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDM7598207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G55570Medicare UPIN