Provider Demographics
NPI:1003971102
Name:KOLAKOWSKI, STEPHEN JR (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:KOLAKOWSKI
Suffix:JR
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 1:19111 TOWN CENTER DR
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-8989
Mailing Address - Country:US
Mailing Address - Phone:760-242-7777
Mailing Address - Fax:
Practice Address - Street 1:13010 HESPERIA RD STE 400
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-8315
Practice Address - Country:US
Practice Address - Phone:760-242-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC1466102086S0129X
NJ25MA08206100208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0133141Medicaid
NJ0133141Medicaid