Healthcare Provider Details

I. General information

NPI: 1518353614
Provider Name (Legal Business Name): JEFFREY KALLAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE BOX MED
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

601 ELMWOOD AVE IMAGING SCIENCES - BOX 648
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-2222
  • Fax:
Mailing address:
  • Phone: 585-275-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number302895-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: