Provider Demographics
NPI:1013108869
Name:COLETSOS, IRENE C (MD)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:C
Last Name:COLETSOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5333 MISSION CENTER RD STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1347
Mailing Address - Country:US
Mailing Address - Phone:619-997-4510
Mailing Address - Fax:619-984-5440
Practice Address - Street 1:5333 MISSION CENTER RD STE 105
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1347
Practice Address - Country:US
Practice Address - Phone:619-997-4510
Practice Address - Fax:619-984-5440
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2565352084P0800X
CAC1962632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry