Provider Demographics
NPI:1083765036
Name:GOLLER, ANCA (MD)
Entity Type:Individual
Prefix:
First Name:ANCA
Middle Name:
Last Name:GOLLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MAYNARD
Mailing Address - State:MA
Mailing Address - Zip Code:01754-2505
Mailing Address - Country:US
Mailing Address - Phone:978-287-8520
Mailing Address - Fax:978-287-8519
Practice Address - Street 1:21 MAIN ST
Practice Address - Street 2:
Practice Address - City:MAYNARD
Practice Address - State:MA
Practice Address - Zip Code:01754-2505
Practice Address - Country:US
Practice Address - Phone:978-287-8520
Practice Address - Fax:978-287-8519
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA246791207RE0101X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110089000AMedicaid
MA110089000AMedicaid