Provider Demographics
NPI:1043476864
Name:WALLACE B KALT MD PC
Entity Type:Organization
Organization Name:WALLACE B KALT MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:B
Authorized Official - Last Name:KALT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-798-3110
Mailing Address - Street 1:930 N BROADWAY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-2394
Mailing Address - Country:US
Mailing Address - Phone:516-798-3110
Mailing Address - Fax:516-798-3605
Practice Address - Street 1:930 N BROADWAY
Practice Address - Street 2:SUITE 3
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-2394
Practice Address - Country:US
Practice Address - Phone:516-798-3110
Practice Address - Fax:516-798-3605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY077178173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty