Provider Demographics
NPI:1396970612
Name:HULBERT, COLEEN D (MD)
Entity type:Individual
Prefix:DR
First Name:COLEEN
Middle Name:D
Last Name:HULBERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:COLEEN
Other - Middle Name:DENISE
Other - Last Name:HASSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:3101 E STATE ST
Practice Address - Street 2:STE 1100
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6232
Practice Address - Country:US
Practice Address - Phone:208-473-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN13814207Q00000X
IDM11814207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20002292Medicare PIN