MEDICARE: DR. MARK WESCOTT NOLLER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	C 54669	CA

General Provider Information

NPI Number	:	1497726095
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK WESCOTT NOLLER M.D.

Provider Business Mailing Address
First Line	:	2460 SAMARITAN DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95124-3907
Country	:	US
Telephone Number	:	408-358-7505
Fax Number	:	408-358-7521

Provider Business Practice Location Address
First Line	:	2550 SAMARITAN DR STE D
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95124-4104
Country	:	US
Telephone Number	:	408-358-7505
Fax Number	:	408-358-7521

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2006
Last Update Date	:	09/07/2016

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