Provider Demographics
NPI:1609161231
Name:KOLTUN, KSENIA (MD)
Entity Type:Individual
Prefix:
First Name:KSENIA
Middle Name:
Last Name:KOLTUN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:KSENIA
Other - Middle Name:KOLTUN
Other - Last Name:STARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3810 CARRIAGE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-1900
Mailing Address - Country:US
Mailing Address - Phone:847-208-8818
Mailing Address - Fax:
Practice Address - Street 1:44201 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1117
Practice Address - Country:US
Practice Address - Phone:248-964-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-11
Last Update Date:2023-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK31106207L00000X
MI4301098662207L00000X
MI4301503468207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology