Provider Demographics
NPI:1629139340
Name:WALLACH, ILISA DAWN (MD)
Entity Type:Individual
Prefix:DR
First Name:ILISA
Middle Name:DAWN
Last Name:WALLACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ILISA
Other - Middle Name:DAWN
Other - Last Name:WALLACH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1421 3RD AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-1899
Mailing Address - Country:US
Mailing Address - Phone:212-717-5700
Mailing Address - Fax:212-717-5706
Practice Address - Street 1:1421 3RD AVE FL 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-1899
Practice Address - Country:US
Practice Address - Phone:212-717-5700
Practice Address - Fax:212-717-5706
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176452207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF47098Medicare UPIN
NY26H211Medicare ID - Type Unspecified