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General NPI Number Information
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NPI Number | 1508860545
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Entity Type | Individual
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Provider Name | GORDON GARY KOLTIS M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/08/2005
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Last Update Date | 09/10/2008
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Provider Practice Location Address
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Address Line | 801 W H SMITH BLVD
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City | GREENVILLE
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State | NC
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Zip | 27834-3764
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Country | US
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Telephone | 252-329-0025
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Fax | 252-329-0325
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Provider Business Mailing Address
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Address Line | 2234 COLONIAL BLVD MANAGED CARE DEPT
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City | FORT MYERS
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State | FL
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Zip | 33907-1412
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Country | US
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Telephone | 239-931-7342
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Fax | 239-931-7385
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0001X
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Taxonomy Name | Radiation Oncology Physician
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License Number | 33390
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 2085R0001X
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Taxonomy Name | Radiation Oncology Physician
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License Number | G86259
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 2085R0001X
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Taxonomy Name | Radiation Oncology Physician
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License Number | ME-0051462
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 2085R0203X
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Taxonomy Name | Therapeutic Radiology Physician
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License Number | MD-035235-E
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License Number State | PA
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Taxonomy #5
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Taxonomy Code | 2085R0203X
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Taxonomy Name | Therapeutic Radiology Physician
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License Number | 247085
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License Number State | WI
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Taxonomy #6
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Taxonomy Code | 2085R0203X
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Taxonomy Name | Therapeutic Radiology Physician
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License Number | MD-018789
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License Number State | TN
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