Provider Demographics
NPI:1225064447
Name:KOLESZAR, MICHELE DIANE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:DIANE
Last Name:KOLESZAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4675 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1813
Mailing Address - Country:US
Mailing Address - Phone:203-372-9998
Mailing Address - Fax:203-373-9095
Practice Address - Street 1:4675 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1813
Practice Address - Country:US
Practice Address - Phone:203-372-9998
Practice Address - Fax:203-373-9095
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028587207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001285875Medicaid
CT16002002Medicare PIN
CTE10237Medicare UPIN