Provider Demographics
NPI:1235233602
Name:KOLATTUKUDY, MARIE M (MD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:M
Last Name:KOLATTUKUDY
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:PO BOX 550979
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33655-0979
Mailing Address - Country:US
Mailing Address - Phone:800-910-9207
Mailing Address - Fax:
Practice Address - Street 1:1000 N EAST 56 ST
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33334
Practice Address - Country:US
Practice Address - Phone:954-351-4796
Practice Address - Fax:954-229-0324
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81705207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL03368Medicare ID - Type Unspecified
B74398Medicare UPIN