Provider Demographics
NPI:1962593947
Name:WALLACH, CARL B (MD)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:B
Last Name:WALLACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:101 OLD SHORT HILLS RD
Mailing Address - Street 2:SUITE 217
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1000
Mailing Address - Country:US
Mailing Address - Phone:973-731-4600
Mailing Address - Fax:973-731-0525
Practice Address - Street 1:101 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-7357
Practice Address - Country:US
Practice Address - Phone:973-455-0404
Practice Address - Fax:973-540-8788
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2014-09-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJMA05476300207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0760901Medicaid
NJE53733Medicare UPIN
NJ614823BQSMedicare PIN