Provider Demographics
NPI:1083614531
Name:KALLAL, JAMES EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:EDWARD
Last Name:KALLAL
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 1:100 RETREAT AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-2528
Mailing Address - Country:US
Mailing Address - Phone:860-522-5712
Mailing Address - Fax:860-520-4270
Practice Address - Street 1:100 RETREAT AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-2528
Practice Address - Country:US
Practice Address - Phone:860-522-5712
Practice Address - Fax:860-520-4270
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT019484207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001194844Medicaid
CTOS2283OtherHEALTHNET ID#
CTP1236548OtherOXFORD HEALTH ID#
CT010019484CT01OtherANTHEM BCBS ID#
CT13459OtherHEALTH NEW ENGLAND ID#
CT2266768003OtherCIGNA ID#
CT2043107OtherAETNA ID#
CT0521150446OtherCONNECTICARE ID#
CTP12038342OtherMULTIPLAN ID#
CTP1236548OtherOXFORD HEALTH ID#
CT001194844Medicaid