Provider Demographics
NPI:1629338470
Name:KOLLER, DEREK (MD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:KOLLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6861 LEMONGRASS LOOP SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-1474
Mailing Address - Country:US
Mailing Address - Phone:361-902-4789
Mailing Address - Fax:361-902-4588
Practice Address - Street 1:6861 LEMONGRASS LOOP SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-1474
Practice Address - Country:US
Practice Address - Phone:361-902-4789
Practice Address - Fax:361-902-4588
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-25
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY284778207Q00000X
IDM-14141207Q00000X
MTMED-PHYS-LIC-60886207Q00000X
CAA143337207Q00000X
CODR.0059780207Q00000X
WAMD60818224207Q00000X
ORMD186008207Q00000X
NMMD2018-0164207Q00000X
NV17828207Q00000X
WY11453A207Q00000X
AZ55553207Q00000X
TXS2376207Q00000X
FLME142837207Q00000X
IL036151000207Q00000X
HI17981207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine