Healthcare Provider Details

I. General information

NPI: 1124010483
Provider Name (Legal Business Name): WILLIAM DAVID KOLTUN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/27/2006
Reactivation Date: 04/12/2006

III. Provider practice location address

9040 FRIARS RD SUITE 540
SAN DIEGO CA
92108-5859
US

IV. Provider business mailing address

9040 FRIARS RD SUITE 540
SAN DIEGO CA
92108-5859
US

V. Phone/Fax

Practice location:
  • Phone: 619-521-2830
  • Fax: 619-521-2830
Mailing address:
  • Phone: 619-521-2830
  • Fax: 619-521-2830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberA030767
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: