Provider Demographics
NPI:1730194150
Name:COLOMBOWALA, ILYAS KAIZAR (MD)
Entity type:Individual
Prefix:
First Name:ILYAS
Middle Name:KAIZAR
Last Name:COLOMBOWALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-0000
Mailing Address - Fax:208-302-0055
Practice Address - Street 1:6140 W CURTISIAN
Practice Address - Street 2:STE 300
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-302-0000
Practice Address - Fax:208-302-0055
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM13580207RC0001X
MT12748207R00000X, 207RC0001X
IDM-13580207RI0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical & Laboratory Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1730194150Medicaid
MT1730194150OtherBCBS
MT1730194150Medicaid