Healthcare Provider Details

I. General information

NPI: 1780684738
Provider Name (Legal Business Name): KOLO NICHOLAS EDIALE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 05/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 HARRIS BUSHVILLE ROAD
MONTICELLO NY
12701
US

IV. Provider business mailing address

68 HARRIS BUSHVILLE RD
HARRIS NY
12742
US

V. Phone/Fax

Practice location:
  • Phone: 845-794-5335
  • Fax: 845-791-4136
Mailing address:
  • Phone: 845-794-9864
  • Fax: 845-794-9868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number220907
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: