Provider Demographics
NPI:1588645550
Name:KALISH, SIDNEY JACK (MD)
Entity Type:Individual
Prefix:
First Name:SIDNEY
Middle Name:JACK
Last Name:KALISH
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 1:14460 GRAVETT RD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1351
Mailing Address - Country:US
Mailing Address - Phone:718-544-2970
Mailing Address - Fax:718-544-6668
Practice Address - Street 1:156 HEWES ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-8901
Practice Address - Country:US
Practice Address - Phone:718-797-3677
Practice Address - Fax:718-544-6668
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113041207W00000X
NJ32123207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00204848Medicaid
C07935Medicare UPIN
NY00204848Medicaid