MEDICARE: GORDON GARY KOLTIS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0203X	Therapeutic Radiology Physician	247085	WI
2	2085R0203X	Therapeutic Radiology Physician	MD-035235-E	PA
3	2085R0001X	Radiation Oncology Physician	G86259	CA
4	2085R0001X	Radiation Oncology Physician	ME-0051462	FL
5	2085R0001X	Radiation Oncology Physician	33390	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	P00612668	OTHER	NC	RAILROAD MEDICARE PTAN
6	30013692	OTHER	NC	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	49898	OTHER	NC	BCBS
2	24-00059	OTHER	NC	UNITED HEALTHCARE
3	9421363-001	OTHER	NC	CIGNA
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508860545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GORDON GARY KOLTIS M.D.

Provider Business Mailing Address
First Line	:	PO BOX 725
Second Line	:
City	:	APEX
State	:	NC
Zip	:	27502-0725
Country	:	US
Telephone Number	:	252-916-1778
Fax Number	:	919-362-0717

Provider Business Practice Location Address
First Line	:	519 DEMOCRACY PL FL 2
Second Line	:
City	:	APEX
State	:	NC
Zip	:	27523-5793
Country	:	US
Telephone Number	:	252-916-1778
Fax Number	:	919-362-0717

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2005
Last Update Date	:	01/15/2026

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