Provider Demographics
NPI:1013951722
Name:ROBERT C KOLOSSEUS MD PC
Entity Type:Organization
Organization Name:ROBERT C KOLOSSEUS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-522-5666
Mailing Address - Street 1:755 S TELSHOR BLVD
Mailing Address - Street 2:STE. 102R
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4688
Mailing Address - Country:US
Mailing Address - Phone:505-522-5666
Mailing Address - Fax:505-522-5680
Practice Address - Street 1:755 S TELSHOR BLVD
Practice Address - Street 2:STE. 102R
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4688
Practice Address - Country:US
Practice Address - Phone:505-522-5666
Practice Address - Fax:505-522-5680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM77444Medicaid
NMDG3601Medicare PIN