Provider Demographics
NPI:1689055931
Name:KOLLODGE, THOMAS S
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
Last Name:KOLLODGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:MT
Mailing Address - Zip Code:59725-3323
Mailing Address - Country:US
Mailing Address - Phone:406-683-2020
Mailing Address - Fax:
Practice Address - Street 1:25 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:MT
Practice Address - Zip Code:59725-3323
Practice Address - Country:US
Practice Address - Phone:406-683-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3395152W00000X
MN3435152W00000X
MTOPT-OPT-LIC-4926152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist