Provider Demographics
NPI:1922156157
Name:NOLLER, DAVID W (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:W
Last Name:NOLLER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2550 SAMARITAN DR STE D
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-4104
Mailing Address - Country:US
Mailing Address - Phone:408-358-7505
Mailing Address - Fax:408-358-7521
Practice Address - Street 1:2550 SAMARITAN DR STE D
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4104
Practice Address - Country:US
Practice Address - Phone:408-358-7505
Practice Address - Fax:408-358-7521
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG-39344208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G303440Medicaid
CA00G303440Medicaid
CA00G393440Medicare ID - Type UnspecifiedMEDICARE