Provider Demographics
NPI:1538197421
Name:KOLLER, STEPHEN M (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:KOLLER
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 1:1119 BASIN HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:BRIDPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05734-9570
Mailing Address - Country:US
Mailing Address - Phone:802-388-8851
Mailing Address - Fax:
Practice Address - Street 1:115 PORTER DR
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-8423
Practice Address - Country:US
Practice Address - Phone:802-388-8851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-00092202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN1562Medicaid
G46152Medicare UPIN
VTVN1562Medicare ID - Type Unspecified