Provider Demographics
NPI:1508860545
Name:KOLTIS, GORDON GARY (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:GARY
Last Name:KOLTIS
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:MANAGED CARE DEPT
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:801 W H SMITH BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3764
Practice Address - Country:US
Practice Address - Phone:252-329-0025
Practice Address - Fax:252-329-0325
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC333902085R0001X
CAG862592085R0001X
FLME-00514622085R0001X
PAMD-035235-E2085R0203X
WI2470852085R0203X
TNMD-0187892085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC49898OtherBCBS
NC24-00059OtherUNITED HEALTHCARE
NC9421363-001OtherCIGNA
NCP00612668OtherRAILROAD MEDICARE PTAN
NC8949898Medicaid
NC30013692OtherRAILROAD MEDICARE
NC49898OtherBCBS
NC24-00059OtherUNITED HEALTHCARE