Healthcare Provider Details

I. General information

NPI: 1720581986
Provider Name (Legal Business Name): ROGER ALAN KOLLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2018
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 PORTWEST CT
RICHMOND VA
23238-5529
US

IV. Provider business mailing address

513 PORTWEST CT
RICHMOND VA
23238-5529
US

V. Phone/Fax

Practice location:
  • Phone: 804-614-5944
  • Fax:
Mailing address:
  • Phone: 804-614-5944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1782
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: