Provider Demographics
NPI:1538372826
Name:JALLER FAMILY MEDICINE, PC
Entity type:Organization
Organization Name:JALLER FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:JALLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-624-5544
Mailing Address - Street 1:4805 TALLAHASSEE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853-3144
Mailing Address - Country:US
Mailing Address - Phone:301-942-9773
Mailing Address - Fax:888-428-2275
Practice Address - Street 1:184 THOMAS JOHNSON DR STE 200
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4561
Practice Address - Country:US
Practice Address - Phone:301-624-5544
Practice Address - Fax:301-624-4164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0033153207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD244PMedicare PIN
MDC34730Medicare UPIN