Provider Demographics
NPI:1629008198
Name:NOLL, CHARLES DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DAVID
Last Name:NOLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:4131 OREGON PIKE
Mailing Address - City:BROWNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17508-0489
Mailing Address - Country:US
Mailing Address - Phone:717-859-1123
Mailing Address - Fax:717-859-2898
Practice Address - Street 1:4131 OREGON PIKE
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:17508-0489
Practice Address - Country:US
Practice Address - Phone:717-859-1123
Practice Address - Fax:717-859-2898
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS004463L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA52793OtherBLUE SHIELD
PA000680630010Medicaid
PA168421OtherTHREE RIVERS
PA4663115OtherAETNA/USHC
PAP002398OtherGATEWAY
PA4663115OtherAETNA/USHC
PA52793OtherBLUE SHIELD