Provider Demographics
NPI:1992813539
Name:KOLB, GARRY R (MD)
Entity type:Individual
Prefix:DR
First Name:GARRY
Middle Name:R
Last Name:KOLB
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 1:695 MORRO AVE
Mailing Address - Street 2:
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93442-2233
Mailing Address - Country:US
Mailing Address - Phone:805-772-2707
Mailing Address - Fax:805-772-0624
Practice Address - Street 1:695 MORRO AVE
Practice Address - Street 2:
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442
Practice Address - Country:US
Practice Address - Phone:805-772-2707
Practice Address - Fax:805-772-0624
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27845207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G27845Medicaid
G27845Medicare ID - Type Unspecified
A43516Medicare UPIN