Provider Demographics
NPI:1972775286
Name:WALI, PRATEEK DHAR (MD)
Entity Type:Individual
Prefix:
First Name:PRATEEK
Middle Name:DHAR
Last Name:WALI
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:725 IRVING AVE
Mailing Address - Street 2:CROUSE POB STE 805
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1603
Mailing Address - Country:US
Mailing Address - Phone:315-464-8444
Mailing Address - Fax:315-464-8445
Practice Address - Street 1:725 IRVING AVE
Practice Address - Street 2:CROUSE POB STE 805
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1603
Practice Address - Country:US
Practice Address - Phone:315-464-8444
Practice Address - Fax:315-464-8445
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2012-09-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY2573942080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03241623Medicaid
NYJ400023353Medicare PIN