Healthcare Provider Details

I. General information

NPI: 1699734012
Provider Name (Legal Business Name): SANFORD KOLTONOW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31815 SOUTHFIELD RD STE 24
BEVERLY HILLS MI
48025-5471
US

IV. Provider business mailing address

31815 SOUTHFIELD RD STE 24
BEVERLY HILLS MI
48025-5471
US

V. Phone/Fax

Practice location:
  • Phone: 248-464-4354
  • Fax:
Mailing address:
  • Phone: 248-464-4354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301045596
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301045596
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: