Provider Demographics
NPI:1073516944
Name:BOLL, JOHN N JR (DO)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:N
Last Name:BOLL
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:740 HIGH ST
Practice Address - Street 2:SUITE 4001
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3100
Practice Address - Country:US
Practice Address - Phone:570-321-2345
Practice Address - Fax:570-321-2359
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010395L207VX0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64052707Medicaid
PA1026698040001Medicaid
KY64052707Medicaid