Provider Demographics
NPI:1851399216
Name:WALLER, JOHN FELIX (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:FELIX
Last Name:WALLER
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 1:333 E 56TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-3758
Mailing Address - Country:US
Mailing Address - Phone:212-289-3236
Mailing Address - Fax:212-289-1880
Practice Address - Street 1:333 E 56TH ST
Practice Address - Street 2:OFC 1
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-3758
Practice Address - Country:US
Practice Address - Phone:212-289-3236
Practice Address - Fax:212-289-1880
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112971174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC11997Medicare UPIN
NY703431Medicare ID - Type Unspecified