Provider Demographics
NPI:1881746360
Name:WALLACK, JOEL J (MD)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:J
Last Name:WALLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:222 E 19TH ST
Mailing Address - Street 2:1D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-2607
Mailing Address - Country:US
Mailing Address - Phone:212-995-7200
Mailing Address - Fax:212-979-3544
Practice Address - Street 1:222 E 19TH ST
Practice Address - Street 2:1D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-2607
Practice Address - Country:US
Practice Address - Phone:212-995-7200
Practice Address - Fax:212-979-3544
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY1283072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO8668Medicare ID - Type Unspecified