Healthcare Provider Details

I. General information

NPI: 1740392737
Provider Name (Legal Business Name): NANCY ELIANA WALLACH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11607 METROPOLITAN AVE STE 101
RICHMOND HILL NY
11418-1018
US

IV. Provider business mailing address

11607 METROPOLITAN AVE STE 101
RICHMOND HILL NY
11418-1018
US

V. Phone/Fax

Practice location:
  • Phone: 718-850-9225
  • Fax: 718-850-9226
Mailing address:
  • Phone: 718-850-9225
  • Fax: 718-850-9226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number224297
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number224297
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: