Provider Demographics
NPI:1477572832
Name:KOLLISCH, DONALD OWEN (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:OWEN
Last Name:KOLLISCH
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 1:93 E WHEELOCK ST
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03755-1605
Mailing Address - Country:US
Mailing Address - Phone:603-643-5572
Mailing Address - Fax:
Practice Address - Street 1:93 E WHEELOCK ST
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:NH
Practice Address - Zip Code:03755-1605
Practice Address - Country:US
Practice Address - Phone:603-643-5572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH6251207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH82086977Medicaid
NH82086977Medicaid
VT0006977Medicare ID - Type Unspecified
B86152Medicare UPIN