Provider Demographics
NPI:1326047036
Name:KOLAKOVICH, THOMAS M (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:M
Last Name:KOLAKOVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1506 OSOLO RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-4122
Mailing Address - Country:US
Mailing Address - Phone:574-264-9635
Mailing Address - Fax:574-262-0398
Practice Address - Street 1:1506 OSOLO RD
Practice Address - Street 2:SUITE A
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-4122
Practice Address - Country:US
Practice Address - Phone:574-264-9635
Practice Address - Fax:574-262-0398
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01032267A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000109324OtherANTHEM BCBS #
INCD5238Medicare PIN
B28630Medicare UPIN
IN184640PMedicare PIN