Healthcare Provider Details

I. General information

NPI: 1558337287
Provider Name (Legal Business Name): CLINT M COLBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 COLUMBINE DRIVE
HOLTON KS
66436
US

IV. Provider business mailing address

1100 COLUMBINE DRIVE
HOLTON KS
66436
US

V. Phone/Fax

Practice location:
  • Phone: 785-364-2116
  • Fax: 785-364-9613
Mailing address:
  • Phone: 785-364-2116
  • Fax: 785-364-9613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6300
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0432089
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-32089
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: