Provider Demographics
NPI:1720015183
Name:STALLER, LEONARD (PA)
Entity Type:Individual
Prefix:MR
First Name:LEONARD
Middle Name:
Last Name:STALLER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:296 N 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08904-2953
Mailing Address - Country:US
Mailing Address - Phone:732-253-0088
Mailing Address - Fax:
Practice Address - Street 1:1033 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3517
Practice Address - Country:US
Practice Address - Phone:973-473-5700
Practice Address - Fax:973-473-3367
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00001000208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology