Provider Demographics
NPI:1518181957
Name:WALLENSTEIN, KIM GABRIELLE (MD, PHD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:GABRIELLE
Last Name:WALLENSTEIN
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:GABRIELLE
Other - Last Name:MENDELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:2 GRAMPIAN RD
Mailing Address - Street 2:APT 9
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-5010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 IRVING AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1603
Practice Address - Country:US
Practice Address - Phone:315-464-2878
Practice Address - Fax:315-464-2879
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2574332086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03254340Medicaid
NY03254340Medicaid