Provider Demographics
NPI:1134222144
Name:MALLER, MARC (MD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:MALLER
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 1:700 E BRIGHTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13205
Mailing Address - Country:US
Mailing Address - Phone:315-413-3279
Mailing Address - Fax:315-469-6558
Practice Address - Street 1:700 E BRIGHTON AVENUE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205
Practice Address - Country:US
Practice Address - Phone:315-413-3279
Practice Address - Fax:315-469-6558
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144029207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA8559Medicare PIN
B88484Medicare UPIN
NYRA7555Medicare PIN