Provider Demographics
NPI:1063518967
Name:STOLLER, KENNETH PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:PAUL
Last Name:STOLLER
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 1:330 PASEO DEL PUEBLO SUR STE J
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-5328
Mailing Address - Country:US
Mailing Address - Phone:505-288-9155
Mailing Address - Fax:
Practice Address - Street 1:330 PASEO DEL PUEBLO SUR STE J
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-5328
Practice Address - Country:US
Practice Address - Phone:505-288-9155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41183207PE0005X, 208000000X
NM97382208000000X, 207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMZ7406Medicaid
NMZ7406Medicaid
H73884Medicare UPIN
CAAV680ZMedicare PIN