MEDICARE: LUCIANO I KOLODNY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	43176-020	WI
2	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	036-103933	IL
3	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	45441	MN

General Provider Information

NPI Number	:	1881653772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUCIANO I KOLODNY MD

Provider Business Mailing Address
First Line	:	12910 12TH ST N
Second Line	:
City	:	LAKE ELMO
State	:	MN
Zip	:	55042-8602
Country	:	US
Telephone Number	:	612-616-4939
Fax Number	:

Provider Business Practice Location Address
First Line	:	12910 12TH ST N
Second Line	:
City	:	LAKE ELMO
State	:	MN
Zip	:	55042-8602
Country	:	US
Telephone Number	:	612-616-4939
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2006
Last Update Date	:	07/02/2024

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