Provider Demographics
NPI:1740392737
Name:WALLACH, NANCY ELIANA (MD)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:ELIANA
Last Name:WALLACH
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11607 METROPOLITAN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-1018
Mailing Address - Country:US
Mailing Address - Phone:718-850-9225
Mailing Address - Fax:718-850-9226
Practice Address - Street 1:11607 METROPOLITAN AVE STE 101
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-1018
Practice Address - Country:US
Practice Address - Phone:718-850-9225
Practice Address - Fax:718-850-9226
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY224297208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02244920Medicaid