Provider Demographics
NPI: | 1447227715 |
---|---|
Name: | KOLTS, BYRON EDWARD (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | BYRON |
Middle Name: | EDWARD |
Last Name: | KOLTS |
Suffix: | |
Gender: | M |
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 44008 |
Mailing Address - Street 2: | UFJP PROVIDER ENROLLMENT |
Mailing Address - City: | JACKSONVILLE |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32231-4008 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 904-244-3660 |
Mailing Address - Fax: | 904-244-3425 |
Practice Address - Street 1: | 655 W 8TH ST |
Practice Address - Street 2: | UFJP GASTROENTEROLOGY |
Practice Address - City: | JACKSONVILLE |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32209-6511 |
Practice Address - Country: | US |
Practice Address - Phone: | 904-244-3273 |
Practice Address - Fax: | 904-244-3425 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-03-04 |
Last Update Date: | 2007-09-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | ME18141 | 207R00000X, 207RG0100X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 01915Z | Medicare PIN | |
FL | D50257 | Medicare UPIN |