Provider Demographics
NPI:1770583882
Name:KALLOZ, JOHN RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RICHARD
Last Name:KALLOZ
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 1:15 RIDGEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:GETTYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17325-8512
Mailing Address - Country:US
Mailing Address - Phone:717-334-4501
Mailing Address - Fax:
Practice Address - Street 1:15 RIDGEWOOD LN
Practice Address - Street 2:
Practice Address - City:GETTYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17325-8512
Practice Address - Country:US
Practice Address - Phone:717-334-4501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD022239E207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD316311300Medicaid
PA000797876Medicaid
PAB36758Medicare UPIN
PA000797876Medicaid
PA108719FLTMedicare PIN
PAP00280218Medicare PIN
PA40465OtherGEISINGER
PA4241473OtherAETNA
PA20090449OtherAMERIHEALTH MERCY-WMG
PA108719OtherHIGHMARK BLUE SHIELD
MD415811OtherCAREFIRST MD BCBS
PA1521521OtherGATEWAY-WMG
PA132414OtherJOHNS HOPKINS
PA175381OtherUNISON-WMG
PA000797876Medicaid