Provider Demographics
NPI:1457354334
Name:KOLTON, BRUCE (MD)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:
Last Name:KOLTON
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 1:160 GREENBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-5024
Mailing Address - Country:US
Mailing Address - Phone:847-945-0773
Mailing Address - Fax:847-945-0776
Practice Address - Street 1:2500 W HIGGINS RD
Practice Address - Street 2:STE 940
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60195-2085
Practice Address - Country:US
Practice Address - Phone:847-839-9999
Practice Address - Fax:847-885-1111
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036047580207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360475801Medicaid
ILC42148Medicare UPIN
IL0360475801Medicaid