Provider Demographics
NPI:1154447209
Name:KOLTUV, MYRON (PHD)
Entity Type:Individual
Prefix:DR
First Name:MYRON
Middle Name:
Last Name:KOLTUV
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 E 10TH ST
Mailing Address - Street 2:1C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-6221
Mailing Address - Country:US
Mailing Address - Phone:212-673-3407
Mailing Address - Fax:212-260-3289
Practice Address - Street 1:50 E 10TH ST
Practice Address - Street 2:1C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-6221
Practice Address - Country:US
Practice Address - Phone:212-673-3407
Practice Address - Fax:212-260-3289
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003060-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical