Provider Demographics
NPI:1255473963
Name:STALLER, JEJERRY
Entity type:Individual
Prefix:MR
First Name:JEJERRY
Middle Name:
Last Name:STALLER
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:STALLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHYSICAL THERAPIST
Mailing Address - Street 1:47 HERITAGE DR APT E
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-5345
Mailing Address - Country:US
Mailing Address - Phone:845-638-0655
Mailing Address - Fax:
Practice Address - Street 1:260 N LITTLE TOR RD
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-2627
Practice Address - Country:US
Practice Address - Phone:845-634-4648
Practice Address - Fax:845-643-7731
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002976225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY22Other002976