Healthcare Provider Details

I. General information

NPI: 1043476864
Provider Name (Legal Business Name): WALLACE B KALT MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 N BROADWAY SUITE 3
MASSAPEQUA NY
11758-2394
US

IV. Provider business mailing address

930 N BROADWAY SUITE 3
MASSAPEQUA NY
11758-2394
US

V. Phone/Fax

Practice location:
  • Phone: 516-798-3110
  • Fax: 516-798-3605
Mailing address:
  • Phone: 516-798-3110
  • Fax: 516-798-3605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number077178
License Number StateNY

VIII. Authorized Official

Name: DR. WALLACE B KALT
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 516-798-3110