Provider Demographics
NPI:1386797306
Name:KOLLER, MARTINA MARY (MD)
Entity type:Individual
Prefix:DR
First Name:MARTINA
Middle Name:MARY
Last Name:KOLLER
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 1:320 NE 97TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-2042
Mailing Address - Country:US
Mailing Address - Phone:206-656-7999
Mailing Address - Fax:206-902-2006
Practice Address - Street 1:320 NE 97TH ST STE C
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-2042
Practice Address - Country:US
Practice Address - Phone:206-656-7999
Practice Address - Fax:206-902-2006
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-21
Last Update Date:2025-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00027370207Q00000X
WAMD00027370207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1118678Medicaid
WA0180024OtherLNI WA STATE
WAG8800318Medicare ID - Type Unspecified