Basic Information
Provider Information | |||||||||
NPI: | 1497847131 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALLER | ||||||||
FirstName: | LEON | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 59 KOCH AVE | ||||||||
Address2: |   | ||||||||
City: | MORRIS PLAINS | ||||||||
State: | NJ | ||||||||
PostalCode: | 079504400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9735381800 | ||||||||
FaxNumber: | 9738898799 | ||||||||
Practice Location | |||||||||
Address1: | 50 POMPTON AVE | ||||||||
Address2: |   | ||||||||
City: | VERONA | ||||||||
State: | NJ | ||||||||
PostalCode: | 070442917 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2018960900 | ||||||||
FaxNumber: | 2018962627 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/29/2006 | ||||||||
LastUpdateDate: | 04/27/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MB340004 | NJ | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 514375 | 01 | NJ | AETNA | OTHER |