Provider Demographics
NPI:1285636753
Name:ROLLER, JOHN ORVILLE (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ORVILLE
Last Name:ROLLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 147
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:MO
Mailing Address - Zip Code:65673-0147
Mailing Address - Country:US
Mailing Address - Phone:417-336-3210
Mailing Address - Fax:417-336-3201
Practice Address - Street 1:1691 S BUS HWY 65
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:MO
Practice Address - Zip Code:65672-6342
Practice Address - Country:US
Practice Address - Phone:417-336-3210
Practice Address - Fax:417-336-3201
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000740213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00357831OtherRR MCR
1261200001Medicare NSC
MOU62417Medicare UPIN