Provider Demographics
NPI:1598932592
Name:KOLESNIKOVA, ANTONINA Y (MD)
Entity type:Individual
Prefix:DR
First Name:ANTONINA
Middle Name:Y
Last Name:KOLESNIKOVA
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 1:1140 VARNUM ST NE PMB 202
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2151
Mailing Address - Country:US
Mailing Address - Phone:202-269-6430
Mailing Address - Fax:202-269-6598
Practice Address - Street 1:1140 VARNUM ST NE PMB 202
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2151
Practice Address - Country:US
Practice Address - Phone:202-269-6430
Practice Address - Fax:202-269-6598
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-09
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD036833302F00000X, 305R00000X, 302R00000X, 305S00000X, 207RN0300X
MDD0069258302R00000X, 305R00000X, 207RN0300X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC055092400Medicaid
MDD0069258OtherLICENSE
DC099023600Medicaid
MD520060100Medicaid
DCMD036833OtherLICENSE