Provider Demographics
NPI:1396851747
Name:KOLETSKY, RICHARD J (M D)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:KOLETSKY
Suffix:
Gender:M
Credentials:M D
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 221244
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-0996
Mailing Address - Country:US
Mailing Address - Phone:216-896-0755
Mailing Address - Fax:216-896-0766
Practice Address - Street 1:23250 CHAGRIN BLVD STE 150
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5417
Practice Address - Country:US
Practice Address - Phone:216-896-0755
Practice Address - Fax:216-896-0766
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35 039588207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHA80413Medicare UPIN