Provider Demographics
NPI:1558352740
Name:FALLER, JASON (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:FALLER
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 1:333 W 57TH ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-3159
Mailing Address - Country:US
Mailing Address - Phone:212-307-6880
Mailing Address - Fax:212-247-6318
Practice Address - Street 1:333 W 57TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3159
Practice Address - Country:US
Practice Address - Phone:212-307-6880
Practice Address - Fax:212-247-6318
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY151022174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY73A521Medicare ID - Type Unspecified
NYB19093Medicare UPIN