Basic Information
| Provider Information | |||||||||
| NPI: | 1487861712 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELMALLAH | ||||||||
| FirstName: | WAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD, MSC, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2110 SILAS DEANE HWY | ||||||||
| Address2: | |||||||||
| City: | ROCKY HILL | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060672353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602583480 | ||||||||
| FaxNumber: | 8605716800 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 LAKE ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | NEW BRITAIN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060521396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602230220 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 02/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35. 091561 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RA0002X | 55451 | CT | N | 207RC0000X | 55451 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 208000000X | 35. 091561 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 207RI0011X | 55451 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | D400332473 | 05 | CT | MEDICAID |