Provider Demographics
NPI:1255544730
Name:DAVID W. NOLLER, M.D. A MEDICAL CORPORATION
Entity type:Organization
Organization Name:DAVID W. NOLLER, M.D. A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:NOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-358-7505
Mailing Address - Street 1:2550 SAMARITAN DR
Mailing Address - Street 2:SUITE D
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
Practice Address - Street 2:SUITE D
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39344207VH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G393440Medicaid
CA00G39344Medicare ID - Type Unspecified
CA00G393440Medicaid