Provider Demographics
NPI:1538396064
Name:HIEBENTHAL, COLLEEN TAMARA (MD)
Entity type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:TAMARA
Last Name:HIEBENTHAL
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 1:530 K ST
Mailing Address - Street 2:#203
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-7058
Mailing Address - Country:US
Mailing Address - Phone:504-237-6546
Mailing Address - Fax:
Practice Address - Street 1:USS COMSTOCK
Practice Address - Street 2:LSD 45
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96662-1733
Practice Address - Country:US
Practice Address - Phone:619-556-3845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068513A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice