Provider Demographics
NPI:1508825175
Name:KOLISZ, ERIC M (OD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:M
Last Name:KOLISZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4380 KINGS WAY
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-6921
Mailing Address - Country:US
Mailing Address - Phone:229-391-4126
Mailing Address - Fax:229-391-4392
Practice Address - Street 1:4380 KINGS WAY
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-6921
Practice Address - Country:US
Practice Address - Phone:229-391-4126
Practice Address - Fax:229-391-4392
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001943152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA92033OtherAVESIS MEDICAID
GA07566OtherSPECTERA
GA081184001OtherCIGNA/PALMETTO DME
GA44257OtherAVESIS GROUP
GA44257OtherAVESIS GROUP
GA41ZCDZNMedicare ID - Type UnspecifiedMEDICARE