Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 038-004839 | IL |
NPI | 1639220353 |
---|---|
Provider Name | Dr. David C Kolbaba |
First Address | West Dundee, IL 60118-2026 |
Second Address | West Dundee, IL 60118-2026 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/01/2007 |
Last Update Date | 28/02/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3500 | DIPLOMATE CLINICAL NUTRIT (01) | IL |
T38082 | (02) | IL |