Provider Demographics
NPI:1548269699
Name:KOLL, WAYNE AL (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:AL
Last Name:KOLL
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:PO BOX 994032
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96099-4032
Mailing Address - Country:US
Mailing Address - Phone:530-241-0473
Mailing Address - Fax:530-241-5377
Practice Address - Street 1:963 BUTTE ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0828
Practice Address - Country:US
Practice Address - Phone:530-245-5900
Practice Address - Fax:530-245-5909
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA675562085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A675560Medicaid
CA00A675560Medicare ID - Type Unspecified
CA00A675560Medicaid