Provider Demographics
NPI:1578571295
Name:KOLLER, CHARLES JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JAY
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 1:2055 GLENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-3307
Mailing Address - Country:US
Mailing Address - Phone:407-645-3555
Mailing Address - Fax:407-645-2555
Practice Address - Street 1:2055 GLENWOOD DR
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3307
Practice Address - Country:US
Practice Address - Phone:407-645-3555
Practice Address - Fax:407-645-2555
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0063666174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF94124Medicare UPIN
FL31339Medicare ID - Type Unspecified