Provider Demographics
NPI:1528147063
Name:KOLLAUS, KENNARD LEE (MD)
Entity type:Individual
Prefix:DR
First Name:KENNARD
Middle Name:LEE
Last Name:KOLLAUS
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:PO BOX 1470
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78853-1470
Mailing Address - Country:US
Mailing Address - Phone:830-773-8917
Mailing Address - Fax:830-773-1892
Practice Address - Street 1:2525 N VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-3302
Practice Address - Country:US
Practice Address - Phone:830-773-5358
Practice Address - Fax:830-773-0258
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1277162-10OtherMEDICAID-TX PROVIDER IDENTIFIER (TPI) # (TYPE: PERFORMING PROVIDER)
TX317812YQEUOtherMEDICARE PROVIDER TRANSACTION ACCESS NUMBER
TX127716203Medicaid
TX00A54TMedicare ID - Type Unspecified
TX1277162-10OtherMEDICAID-TX PROVIDER IDENTIFIER (TPI) # (TYPE: PERFORMING PROVIDER)