Provider Demographics
NPI:1275654295
Name:NOLL, ROBERT EDWIN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWIN
Last Name:NOLL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10535 HOSPITAL WAY
Mailing Address - Street 2:SURGICAL SERVICE (112/SMAT)
Mailing Address - City:MATHER
Mailing Address - State:CA
Mailing Address - Zip Code:95655-4200
Mailing Address - Country:US
Mailing Address - Phone:916-843-9388
Mailing Address - Fax:
Practice Address - Street 1:10535 HOSPITAL WAY
Practice Address - Street 2:SURGICAL SERVICE (112/SMAT)
Practice Address - City:MATHER
Practice Address - State:CA
Practice Address - Zip Code:95655-4200
Practice Address - Country:US
Practice Address - Phone:916-843-9388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC54369208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04009361Medicaid
LA1077691Medicaid
LA4N092Medicare PIN
LA1077691Medicaid