Provider Demographics
NPI:1740351683
Name:KOLANSKY, GLENN (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:KOLANSKY
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 1:4 HARTFORD DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4929
Mailing Address - Country:US
Mailing Address - Phone:732-933-8500
Mailing Address - Fax:732-933-4177
Practice Address - Street 1:4 HARTFORD DR
Practice Address - Street 2:SUITE 3
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07701-4929
Practice Address - Country:US
Practice Address - Phone:732-933-8500
Practice Address - Fax:732-933-4177
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06217900207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F57665Medicare UPIN
NJ782889Medicare ID - Type Unspecified