Provider Demographics
NPI:1649256066
Name:WALLACH, BRUCE HARRIS (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:HARRIS
Last Name:WALLACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BRUCE
Other - Middle Name:H
Other - Last Name:WALLACH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:629 CRANBURY RD FL 2
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-4096
Mailing Address - Country:US
Mailing Address - Phone:732-390-7750
Mailing Address - Fax:732-390-7725
Practice Address - Street 1:34-36 PROGRESS ST.
Practice Address - Street 2:SUITE B-2
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820
Practice Address - Country:US
Practice Address - Phone:908-757-9696
Practice Address - Fax:908-757-9721
Is Sole Proprietor?:No
Enumeration Date:2005-12-17
Last Update Date:2023-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207RH0003X207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ751594CTKOtherMEDICAREID
NJ7534809Medicaid
NJ1790396281OtherTITAN HEALTH GROUP NPI#
22-3254679OtherBLUESHEILD
F74151Medicare UPIN
2K3238Medicare ID - Type UnspecifiedHEALTH NET