Provider Demographics
NPI:1760621759
Name:KOLLMORGEN, ROBERT CHARLES (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:CHARLES
Last Name:KOLLMORGEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 E DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1431
Mailing Address - Country:US
Mailing Address - Phone:559-453-5200
Mailing Address - Fax:559-453-5233
Practice Address - Street 1:604 N MAGNOLIA AVE STE 100
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-9205
Practice Address - Country:US
Practice Address - Phone:559-320-0531
Practice Address - Fax:559-320-0539
Is Sole Proprietor?:No
Enumeration Date:2009-02-13
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11856207XS0114X, 207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH345370Medicare PIN
OH34011288OtherOHIO MEDICAL LICENSE
OH0107856Medicaid