Provider Demographics
NPI:1760921043
Name:STALLER, BRANDEN
Entity Type:Individual
Prefix:
First Name:BRANDEN
Middle Name:
Last Name:STALLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08904-2113
Mailing Address - Country:US
Mailing Address - Phone:732-874-6063
Mailing Address - Fax:
Practice Address - Street 1:23 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:08904-2113
Practice Address - Country:US
Practice Address - Phone:732-874-6063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-19
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP05157207Q00000X
NJ25MA10916500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine