Provider Demographics
NPI:1487634978
Name:OLLER, RICHARD M (DPM)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
Last Name:OLLER
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 1:136 E BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-3428
Mailing Address - Country:US
Mailing Address - Phone:610-565-3377
Mailing Address - Fax:610-565-5351
Practice Address - Street 1:136 E BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-3428
Practice Address - Country:US
Practice Address - Phone:610-565-3377
Practice Address - Fax:610-565-5351
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002111L213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA480000978OtherRAILROAD MEDICARE
PA0032744000OtherBLUE SHIELD ID
PA0935190001Medicare NSC
PA480000978OtherRAILROAD MEDICARE
PAT29571Medicare UPIN