Provider Demographics
NPI:1730340340
Name:KOLEILAT, ISSAM (MD)
Entity type:Individual
Prefix:DR
First Name:ISSAM
Middle Name:
Last Name:KOLEILAT
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 1:67 ROUTE 37 W STE 200B
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-6400
Mailing Address - Country:US
Mailing Address - Phone:732-341-3647
Mailing Address - Fax:
Practice Address - Street 1:67 ROUTE 37 W STE 200B
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-6400
Practice Address - Country:US
Practice Address - Phone:732-341-3647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09883400208600000X, 2086S0129X
NY2798952086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
62732OtherAMC ID NUMBER