Provider Demographics
NPI:1306892039
Name:KOLODZIK, JOAN M (MD)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:KOLODZIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4381
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:45005-2584
Practice Address - Country:US
Practice Address - Phone:513-312-3656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35055905207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000315972OtherBCBS FOR UVMC
OH0713973Medicaid
OH000000317227OtherBCBS
P00114921OtherRR MEDICARE FOR UMVC
OH0713973Medicaid
OH000000315972OtherBCBS FOR UVMC
P00114921OtherRR MEDICARE FOR UMVC