Provider Demographics
NPI:1992780258
Name:COLLER, DALE A (DO)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:A
Last Name:COLLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:854 WASHINGTON AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7147
Mailing Address - Country:US
Mailing Address - Phone:616-395-2853
Mailing Address - Fax:616-393-5319
Practice Address - Street 1:854 WASHINGTON AVE STE 150
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7147
Practice Address - Country:US
Practice Address - Phone:616-395-2853
Practice Address - Fax:616-393-5319
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013369207R00000X, 207RC0200X, 207RS0012X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4540244Medicaid
MIH94973Medicare UPIN
MI4540244Medicaid