Provider Demographics
NPI:1821198490
Name:KOLETTIS, GEORGE JOHN (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:JOHN
Last Name:KOLETTIS
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 1:660 GLADES RD
Mailing Address - Street 2:SUITE 460
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6465
Mailing Address - Country:US
Mailing Address - Phone:561-391-5515
Mailing Address - Fax:561-347-7470
Practice Address - Street 1:660 GLADES RD
Practice Address - Street 2:SUITE 460
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6465
Practice Address - Country:US
Practice Address - Phone:561-391-5515
Practice Address - Fax:561-347-7470
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68398174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF61410Medicare UPIN
FL27477UMedicare PIN