Provider Demographics
NPI:1588721195
Name:KOLLER, JOHN M (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:KOLLER
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 1126
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-1126
Mailing Address - Country:US
Mailing Address - Phone:907-486-6188
Mailing Address - Fax:907-486-6146
Practice Address - Street 1:202 CENTER AVE.
Practice Address - Street 2:STE. 102
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-1126
Practice Address - Country:US
Practice Address - Phone:907-486-6188
Practice Address - Fax:907-486-6146
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3737207Q00000X
AKS3737207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
K151630OtherMEDICARE ID ( DEACTIVATED AFTER 5.16.09)
AKMD10072Medicaid
K162501OtherMEDICARE ID 6.29.09 - PRESENT
AKMD10072Medicaid