Provider Demographics
NPI:1326219577
Name:WALLER, ALFONSO (MD)
Entity Type:Individual
Prefix:DR
First Name:ALFONSO
Middle Name:
Last Name:WALLER
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 1:90 BERGEN ST
Mailing Address - Street 2:SUITE 3500
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2425
Mailing Address - Country:US
Mailing Address - Phone:973-972-2573
Mailing Address - Fax:
Practice Address - Street 1:90 BERGEN ST
Practice Address - Street 2:SUITE 3500
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2425
Practice Address - Country:US
Practice Address - Phone:973-972-2573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08557800207RC0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease