Healthcare Provider Details

I. General information

NPI: 1700463502
Provider Name (Legal Business Name): DANIEL KALLUSH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 GARDEN ST
BERGENFIELD NJ
07621-2744
US

IV. Provider business mailing address

70 GARDEN ST
BERGENFIELD NJ
07621-2744
US

V. Phone/Fax

Practice location:
  • Phone: 215-410-1066
  • Fax:
Mailing address:
  • Phone: 215-410-1066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS023104
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: