Provider Demographics
NPI:1720163173
Name:WOLLOCH, DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:WOLLOCH
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 1:870 PALISADE AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-3419
Mailing Address - Country:US
Mailing Address - Phone:201-692-1661
Mailing Address - Fax:201-692-9219
Practice Address - Street 1:870 PALISADE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-3419
Practice Address - Country:US
Practice Address - Phone:201-692-1661
Practice Address - Fax:201-692-9219
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230115208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0225444Medicaid