Provider Demographics
NPI:1528018975
Name:KONKEL, COLLEEN NICOLE (OD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:NICOLE
Last Name:KONKEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4344 MORMON COULEE RD
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-7908
Mailing Address - Country:US
Mailing Address - Phone:608-788-8800
Mailing Address - Fax:
Practice Address - Street 1:4344 MORMON COULEE RD
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-7908
Practice Address - Country:US
Practice Address - Phone:608-788-8800
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2780152W00000X
WI2845152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38612600Medicaid
WI81870Medicare UPIN
WI0006Medicare ID - Type Unspecified