Provider Demographics
NPI:1205823457
Name:KOLOSSEUS, RAY C (MD)
Entity Type:Individual
Prefix:DR
First Name:RAY
Middle Name:C
Last Name:KOLOSSEUS
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 1:755 S TELSHOR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4681
Mailing Address - Country:US
Mailing Address - Phone:505-522-5666
Mailing Address - Fax:505-522-5680
Practice Address - Street 1:755 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4688
Practice Address - Country:US
Practice Address - Phone:505-522-5666
Practice Address - Fax:505-522-5680
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM75-185174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMC97896Medicare UPIN
NM2127125Medicare ID - Type Unspecified