Healthcare Provider Details

I. General information

NPI: 1154591519
Provider Name (Legal Business Name): STEVEN BLAKE COLSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2008
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 DESOTO ST
IDAHO FALLS ID
83404-7570
US

IV. Provider business mailing address

2330 DESOTO ST
IDAHO FALLS ID
83404-7570
US

V. Phone/Fax

Practice location:
  • Phone: 208-528-1039
  • Fax: 208-528-1939
Mailing address:
  • Phone: 208-528-1039
  • Fax: 208-528-1939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberM-17030
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: