Provider Demographics
NPI:1336229830
Name:WALLACH, STEVEN GREGG (MD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:GREGG
Last Name:WALLACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1049 5TH AVE STE 2D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0115
Mailing Address - Country:US
Mailing Address - Phone:212-861-6400
Mailing Address - Fax:212-535-3948
Practice Address - Street 1:1049 5TH AVE STE 2D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0115
Practice Address - Country:US
Practice Address - Phone:212-861-6400
Practice Address - Fax:212-535-3948
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY187315208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY39I851Medicare ID - Type Unspecified
NYF73038Medicare UPIN