Provider Demographics
NPI:1124015946
Name:HALLER, MELVIN LEE (MD)
Entity type:Individual
Prefix:MR
First Name:MELVIN
Middle Name:LEE
Last Name:HALLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3074 36TH ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-4705
Mailing Address - Country:US
Mailing Address - Phone:718-728-0224
Mailing Address - Fax:718-728-1626
Practice Address - Street 1:3074 36TH ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-4705
Practice Address - Country:US
Practice Address - Phone:718-728-0224
Practice Address - Fax:718-728-1626
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112942207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00242526Medicaid
NY01353HMedicare PIN
NY00242526Medicaid