Provider Demographics
NPI:1588952188
Name:KOLSTAD PLASTIC SURGERY, INC
Entity type:Organization
Organization Name:KOLSTAD PLASTIC SURGERY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-859-2563
Mailing Address - Street 1:4180 LA JOLLA VILLAGE DR
Mailing Address - Street 2:SUITE 455
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-859-2563
Mailing Address - Fax:858-999-3541
Practice Address - Street 1:4180 LA JOLLA VILLAGE DR
Practice Address - Street 2:SUITE 455
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037
Practice Address - Country:US
Practice Address - Phone:858-859-2563
Practice Address - Fax:858-999-3541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207YX0905X
CAA100294207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Multi-Specialty
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFD680AMedicare PIN