Provider Demographics
NPI:1962431445
Name:RALLATOS, MICHAEL (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:RALLATOS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:NJ
Mailing Address - Zip Code:07033-1657
Mailing Address - Country:US
Mailing Address - Phone:908-276-6624
Mailing Address - Fax:908-709-0163
Practice Address - Street 1:528 BOULEVARD
Practice Address - Street 2:
Practice Address - City:KENILWORTH
Practice Address - State:NJ
Practice Address - Zip Code:07033-1657
Practice Address - Country:US
Practice Address - Phone:908-276-6624
Practice Address - Fax:908-709-0163
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00286500213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8719501Medicaid
NJ8719501Medicaid
NJ052915Medicare PIN