Provider Demographics
NPI:1508824400
Name:NOLLER, KENNETH L (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
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 1:14 HIGH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-1673
Mailing Address - Country:US
Mailing Address - Phone:617-636-2382
Mailing Address - Fax:
Practice Address - Street 1:BOX 324, WASHINGTON ST.
Practice Address - Street 2:NEW ENGLAND MEDICAL CENTER
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111
Practice Address - Country:US
Practice Address - Phone:617-636-2382
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA70287207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology