Provider Demographics
NPI:1699734012
Name:KOLTONOW, SANFORD (MD)
Entity type:Individual
Prefix:DR
First Name:SANFORD
Middle Name:
Last Name:KOLTONOW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31815 SOUTHFIELD RD STE 24
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-5471
Mailing Address - Country:US
Mailing Address - Phone:248-464-4354
Mailing Address - Fax:
Practice Address - Street 1:31815 SOUTHFIELD RD STE 24
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:MI
Practice Address - Zip Code:48025-5471
Practice Address - Country:US
Practice Address - Phone:248-464-4354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC1900X, 103TP0814X
MI4301045596207P00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI010F362410OtherBCBSM
MI1577750Medicaid