=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609674738
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLBY DOUGLAS EDMONDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2025
-----------------------------------------------------
Last Update Date | 03/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 334 N 4440 E
-----------------------------------------------------
City | RIGBY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83442-5887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-590-4449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 334 N 4440 E
-----------------------------------------------------
City | RIGBY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83442-5887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-590-4449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 4071459
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------