Provider Demographics
NPI:1649208091
Name:KOLLE, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:KOLLE
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 1:251 COUNTY RD 120
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4665
Mailing Address - Country:US
Mailing Address - Phone:320-202-8949
Mailing Address - Fax:320-202-0756
Practice Address - Street 1:1301 33RD ST S
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301
Practice Address - Country:US
Practice Address - Phone:320-251-8181
Practice Address - Fax:320-251-6942
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33564207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN917500800Medicaid
MN080008435Medicare PIN
MN917500800Medicaid