Provider Demographics
NPI:1487861712
Name:ELMALLAH, WAEL (MD, MSC, PHD)
Entity Type:Individual
Prefix:DR
First Name:WAEL
Middle Name:
Last Name:ELMALLAH
Suffix:
Gender:M
Credentials:MD, MSC, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-2353
Mailing Address - Country:US
Mailing Address - Phone:860-258-3480
Mailing Address - Fax:860-571-6800
Practice Address - Street 1:1 LAKE ST
Practice Address - Street 2:SUITE 204
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1396
Practice Address - Country:US
Practice Address - Phone:860-223-0220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35. 091561207R00000X, 208000000X
CT55451207RA0002X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0002XAllopathic & Osteopathic PhysiciansInternal MedicineAdult Congenital Heart Disease
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400332473Medicaid