Provider Demographics
NPI:1972570802
Name:KOLESK, STEPHEN J (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:KOLESK
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 1:7000 ATRIUM WAY
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-3917
Mailing Address - Country:US
Mailing Address - Phone:856-840-4500
Mailing Address - Fax:856-234-4241
Practice Address - Street 1:1636 ROUTE 38 & EAYRESTOWN ROAD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NJ
Practice Address - Zip Code:08048-0000
Practice Address - Country:US
Practice Address - Phone:609-914-8440
Practice Address - Fax:609-914-8441
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03638700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0213705Medicaid
NJ0213705Medicaid
NJC58924Medicare UPIN