Provider Demographics
NPI:1093708067
Name:NOLL, DONALD R (DO)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:R
Last Name:NOLL
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 1:42 E LAUREL RD STE 1800
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1338
Mailing Address - Country:US
Mailing Address - Phone:856-566-6843
Mailing Address - Fax:856-566-6419
Practice Address - Street 1:42 E LAUREL RD STE 1800
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1338
Practice Address - Country:US
Practice Address - Phone:856-566-6843
Practice Address - Fax:856-566-6419
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05445900207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0225967Medicaid
NJ177121CKPMedicare PIN
F38417Medicare UPIN