Basic Information
| Provider Information | |||||||||
| NPI: | 1255318036 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STOLLER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6102 | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949486102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158843418 | ||||||||
| FaxNumber: | 4158838082 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 CALIFORNIA ST | ||||||||
| Address2: | SUITE G350 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941181618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156002940 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 06/01/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G50834 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 5855 | AK | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 35464 | AZ | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 30786 | CO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 25MA07189700 | NJ | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 207K00000X | 036.103835 | IL | N | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 0144894 | 01 | WA | L&I | OTHER | 1255318036 | 05 | NV | MEDICAID | 8169690 | 05 | WA | MEDICAID | 300123273 | 01 | WA | RAILROAD MEDICARE | OTHER | 111845 | 05 | AZ | MEDICAID | 200097670A | 05 | OK | MEDICAID | 8940207 | 05 | NJ | MEDICAID | 300121756 | 01 | CA | RAILROAD MEDICARE | OTHER | 8933500 | 01 | WA | L&I, CVCP | OTHER | 93723288 | 05 | CO | MEDICAID | G00508340 | 05 | CA | MEDICAID |