Provider Demographics
NPI:1619981164
Name:ZIMMERMANN, KOLLEEN L (MD)
Entity Type:Individual
Prefix:DR
First Name:KOLLEEN
Middle Name:L
Last Name:ZIMMERMANN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KOLLEEN
Other - Middle Name:L
Other - Last Name:KRUZAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2461 HOLMGREN WAY
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5224
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:715 SUPERIOR RD STE 120
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-7595
Practice Address - Country:US
Practice Address - Phone:920-406-9803
Practice Address - Fax:920-406-9934
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38042-020207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI070016223OtherRAILROAD MEDICARE
WI32561400Medicaid