Provider Demographics
NPI:1831445550
Name:SHALLER, DAVID A (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:SHALLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:259 CHURCH ST
Mailing Address - Street 2:APT 32
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5331
Mailing Address - Country:US
Mailing Address - Phone:570-287-8524
Mailing Address - Fax:570-268-8524
Practice Address - Street 1:71 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:TOWANDA
Practice Address - State:PA
Practice Address - Zip Code:18848-9706
Practice Address - Country:US
Practice Address - Phone:570-265-6300
Practice Address - Fax:570-268-2807
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD030260E207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014906210004Medicaid
PA0014906210004Medicaid
PAF38709Medicare UPIN