Provider Demographics
NPI:1134154792
Name:WALLE, ALEXANDER JORG (MD PHD)
Entity type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:JORG
Last Name:WALLE
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 211261
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421
Mailing Address - Country:US
Mailing Address - Phone:718-456-5600
Mailing Address - Fax:
Practice Address - Street 1:13223 79TH ST
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11417-1137
Practice Address - Country:US
Practice Address - Phone:718-456-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY162148207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01345073Medicaid
NY04310OtherMEDICARE ID
F24541Medicare UPIN
NY04310OtherMEDICARE ID