Provider Demographics
NPI:1023049228
Name:NOLLER, WILLIAM EDWARD (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:EDWARD
Last Name:NOLLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4620 S LABURNUM AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23231-2424
Mailing Address - Country:US
Mailing Address - Phone:804-652-2200
Mailing Address - Fax:804-222-0458
Practice Address - Street 1:4620 S LABURNUM AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23231-2424
Practice Address - Country:US
Practice Address - Phone:804-652-2200
Practice Address - Fax:804-222-0458
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101041328207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA79151OtherSOUTHERN HEALTH SERVICES
VA293612OtherMAMSI
VA12673OtherSENTARA
VA333716OtherANTHEM BCBS OF VA
VA4206388OtherAETNA LIFE
VA4206388OtherAETNA HMO
VA005613159Medicaid
VA0856408OtherCIGNA
VA080125347OtherRAILROAD MEDICARE
VA293612OtherMAMSI
VA333716OtherANTHEM BCBS OF VA