Healthcare Provider Details

I. General information

NPI: 1497044234
Provider Name (Legal Business Name): MICHAEL A KOLDOBSKIY M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 11/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST CMSC 2-124
BALTIMORE MD
21287-3224
US

IV. Provider business mailing address

9910 FRANKLIN SQUARE DR STE 2110
BALTIMORE MD
21236-4902
US

V. Phone/Fax

Practice location:
  • Phone: 410-614-4493
  • Fax:
Mailing address:
  • Phone: 410-933-6423
  • Fax: 410-933-1390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberD77993
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: