Provider Demographics
NPI:1568532240
Name:EKHOLM, COLLYER (MD)
Entity Type:Individual
Prefix:
First Name:COLLYER
Middle Name:
Last Name:EKHOLM
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:PO BOX 17779
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85011-0779
Mailing Address - Country:US
Mailing Address - Phone:602-374-7522
Mailing Address - Fax:602-237-6997
Practice Address - Street 1:520 11TH ST NW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52405-3811
Practice Address - Country:US
Practice Address - Phone:319-398-3562
Practice Address - Fax:319-398-3501
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2016-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA245832084P0800X
CO280262084P0800X
AZ188712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAE07092Medicare UPIN