Provider Demographics
NPI:1801391438
Name:WALLER, GIACOMO COLVER (MD)
Entity Type:Individual
Prefix:DR
First Name:GIACOMO
Middle Name:COLVER
Last Name:WALLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:19 E 98TH ST, 7TH FL
Mailing Address - Street 2:STE A, BOX #1259
Mailing Address - City:NY
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6574
Mailing Address - Country:US
Mailing Address - Phone:212-241-0949
Mailing Address - Fax:212-534-2654
Practice Address - Street 1:19 E 98TH ST, 7TH FL
Practice Address - Street 2:STE A, BOX #1259
Practice Address - City:NY
Practice Address - State:NY
Practice Address - Zip Code:10029-6574
Practice Address - Country:US
Practice Address - Phone:212-241-0949
Practice Address - Fax:212-534-2654
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2023-07-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL125.077143208600000X, 390200000X
GA390200000X
NY322610208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125.077143OtherILLINOISE DFPR
NY322610OtherNEW YORK STATE EDUCATION DEPARTMENT OFFICE OF THE PROFESSIONS