Provider Demographics
NPI:1720088289
Name:COLOMBO, GREGORY R (DC)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:R
Last Name:COLOMBO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9549 TAYLORSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2734
Mailing Address - Country:US
Mailing Address - Phone:502-261-0713
Mailing Address - Fax:502-261-0771
Practice Address - Street 1:9549 TAYLORSVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-2734
Practice Address - Country:US
Practice Address - Phone:502-261-0713
Practice Address - Fax:502-261-0771
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4656111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000356981OtherANTHEM
201794428OtherPHCS
KY0964201Medicare PIN
KY000000356981OtherANTHEM