Provider Demographics
NPI:1548251713
Name:HALLER, CHAD BENJAMIN (MD)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:BENJAMIN
Last Name:HALLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3720 INDEPENDENCE AVE
Mailing Address - Street 2:APT #1F
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-1429
Mailing Address - Country:US
Mailing Address - Phone:917-743-3462
Mailing Address - Fax:718-728-0626
Practice Address - Street 1:3074 36TH ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-4705
Practice Address - Country:US
Practice Address - Phone:718-728-0224
Practice Address - Fax:718-728-1626
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY223411207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2577791Medicaid
NY2577791Medicaid
NYI22710Medicare UPIN