Provider Demographics
NPI:1093772097
Name:KOLES, PAUL G (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:G
Last Name:KOLES
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 1:725 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45435-0001
Mailing Address - Country:US
Mailing Address - Phone:937-245-7100
Mailing Address - Fax:937-245-7999
Practice Address - Street 1:3640 COLONEL GLENN HWY
Practice Address - Street 2:125 WHITE HALL
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45435-0001
Practice Address - Country:US
Practice Address - Phone:937-775-2625
Practice Address - Fax:937-775-2633
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35046638207ZC0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0667961Medicaid
OHKO0785642Medicare PIN
OH0667961Medicaid