Provider Demographics
NPI:1841221397
Name:KOLODZIEJ, B ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:B
Middle Name:ALLEN
Last Name:KOLODZIEJ
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 1:1707 BUCCANEER DR
Mailing Address - Street 2:APT 312
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-7736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 COMBS RD
Practice Address - Street 2:
Practice Address - City:PENNINGTON GAP
Practice Address - State:VA
Practice Address - Zip Code:24277-1808
Practice Address - Country:US
Practice Address - Phone:276-546-1440
Practice Address - Fax:865-291-3228
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233338207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAI40926Medicare UPIN
VA008549E59Medicare ID - Type Unspecified