Provider Demographics
NPI:1346245891
Name:KOLETTIS, ELIAS M (DO)
Entity Type:Individual
Prefix:
First Name:ELIAS
Middle Name:M
Last Name:KOLETTIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:KOLETTIS KREW
Other - Middle Name:
Other - Last Name:LLC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:701 N HERCULES AVE
Mailing Address - Street 2:STE B
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33765-2029
Mailing Address - Country:US
Mailing Address - Phone:727-738-8410
Mailing Address - Fax:727-734-6254
Practice Address - Street 1:701 N HERCULES AVE
Practice Address - Street 2:STE B
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-2029
Practice Address - Country:US
Practice Address - Phone:727-738-8410
Practice Address - Fax:727-734-6254
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7623207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL46556OtherBCBS
FL255469100Medicaid
FL255469100Medicaid
FL46556OtherBCBS