Healthcare Provider Details

I. General information

NPI: 1871763979
Provider Name (Legal Business Name): JEROME FRANCIS KOLESKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 E AJO WAY
TUCSON AZ
85713
US

IV. Provider business mailing address

2800 E. AJO WAY
TUCSON AZ
85713
US

V. Phone/Fax

Practice location:
  • Phone: 520-874-4800
  • Fax:
Mailing address:
  • Phone: 520-874-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24504
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: