Provider Demographics
NPI:1124123567
Name:KOLL, THOMAS J (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:KOLL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3780 GRANADA PLAZA NO
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128
Mailing Address - Country:US
Mailing Address - Phone:651-779-2130
Mailing Address - Fax:
Practice Address - Street 1:418 WEST 3RD ST
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55065
Practice Address - Country:US
Practice Address - Phone:651-388-0738
Practice Address - Fax:651-388-0739
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1928152W00000X
WI1879152W00000X
OR1599152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN283R6K0OtherBCBS
MN2202055OtherMEDICA
MN283R6K0OtherBCBS