Provider Demographics
NPI:1710059209
Name:KALLIEL, JOHN NADER (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:NADER
Last Name:KALLIEL
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 1:765 SOUTH MAIN STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102
Mailing Address - Country:US
Mailing Address - Phone:603-668-6444
Mailing Address - Fax:603-668-6762
Practice Address - Street 1:765 SOUTH MAIN STREET
Practice Address - Street 2:SUITE 203
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102
Practice Address - Country:US
Practice Address - Phone:603-668-6444
Practice Address - Fax:603-668-6762
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH7573174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30010246Medicaid
A67869Medicare UPIN
KAWH9358Medicare ID - Type Unspecified