Provider Demographics
NPI:1629827035
Name:KOLOSHA, MERCADES (RDMS)
Entity type:Individual
Prefix:
First Name:MERCADES
Middle Name:
Last Name:KOLOSHA
Suffix:
Gender:F
Credentials:RDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8400 S. KALANCHOE AVE.
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011
Mailing Address - Country:US
Mailing Address - Phone:918-574-1134
Mailing Address - Fax:
Practice Address - Street 1:8400 S KALANCHOE AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-7810
Practice Address - Country:US
Practice Address - Phone:918-574-1134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile