Provider Demographics
NPI:1912404609
Name:KOLBERG, ERIK (BCO)
Entity Type:Individual
Prefix:MR
First Name:ERIK
Middle Name:
Last Name:KOLBERG
Suffix:
Gender:M
Credentials:BCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9663 TIERRA GRANDE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4570
Mailing Address - Country:US
Mailing Address - Phone:858-695-2021
Mailing Address - Fax:858-695-2712
Practice Address - Street 1:9663 TIERRA GRANDE ST STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4570
Practice Address - Country:US
Practice Address - Phone:858-695-2021
Practice Address - Fax:858-695-2712
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1164466488Medicaid