Healthcare Provider Details

I. General information

NPI: 1164834073
Provider Name (Legal Business Name): COLBY BINGHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2014
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1344 HILAND AVE STE D
BURLEY ID
83318-1564
US

IV. Provider business mailing address

4021 CALLOWAY DR
RIGBY ID
83442-5293
US

V. Phone/Fax

Practice location:
  • Phone: 208-572-6005
  • Fax:
Mailing address:
  • Phone: 208-680-5943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberM-13572
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: