Healthcare Provider Details

I. General information

NPI: 1972730380
Provider Name (Legal Business Name): WILLIAM A BOLLER III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WAHOO AVE
GROTON CT
06349-2324
US

IV. Provider business mailing address

1 WAHOO AVE
GROTON CT
06349-2324
US

V. Phone/Fax

Practice location:
  • Phone: 860-694-2377
  • Fax: 860-694-2590
Mailing address:
  • Phone: 860-694-2377
  • Fax: 860-694-2590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD24366
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101250100
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: