Provider Demographics
NPI:1962441139
Name:COULOMBE, PAUL R (MD)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:R
Last Name:COULOMBE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10595 N TATUM BLVD STE E144
Mailing Address - Street 2:
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-1072
Mailing Address - Country:US
Mailing Address - Phone:480-588-6970
Mailing Address - Fax:480-588-7340
Practice Address - Street 1:10595 N TATUM BLVD STE E144
Practice Address - Street 2:
Practice Address - City:PARADISE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85253-1072
Practice Address - Country:US
Practice Address - Phone:480-588-6970
Practice Address - Fax:480-588-7340
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21251207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ161050Medicaid
63713Medicare ID - Type Unspecified
AZ161050Medicaid