Provider Demographics
NPI:1336147917
Name:KALLOR, SCOTT MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:MICHAEL
Last Name:KALLOR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 BLOOMFIELD AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-2479
Mailing Address - Country:US
Mailing Address - Phone:860-286-0444
Mailing Address - Fax:860-286-0464
Practice Address - Street 1:705 BLOOMFIELD AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2479
Practice Address - Country:US
Practice Address - Phone:860-286-0444
Practice Address - Fax:860-286-0464
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042001208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001420017Medicaid