Provider Demographics
NPI:1720581986
Name:KOLLER, ROGER ALAN
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:ALAN
Last Name:KOLLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 PORTWEST CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23238-5529
Mailing Address - Country:US
Mailing Address - Phone:804-614-5944
Mailing Address - Fax:
Practice Address - Street 1:513 PORTWEST CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23238-5529
Practice Address - Country:US
Practice Address - Phone:804-614-5944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA175T00000X
VA1782175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist