1417068115 NPI number — BRYANT HALIBURTON MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417068115 NPI number — BRYANT HALIBURTON MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

HALIBURTON

Provider First Name:

BRYANT

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1417068115

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

08/11/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

11510 GEORGIA AVE

Provider Second Line Business Mailing Address:

SUITE 206

Provider Business Mailing Address City Name:

WHEATON

Provider Business Mailing Address State Name:

MD

Provider Business Mailing Address Postal Code:

20902-1925

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

301-946-5100

Provider Business Mailing Address Fax Number:

301-929-0348

Provider First Line Business Practice Location Address:

110 IRVING ST NW

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

WASHINGTON

Provider Business Practice Location Address State Name:

DC

Provider Business Practice Location Address Postal Code:

20010-2976

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

301-946-5100

Provider Business Practice Location Address Fax Number:

301-929-0348

Provider Enumeration Date:

08/31/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207L00000X , with the licence number:  MD034253 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207L00000X , with the licence number: MD428012 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207L00000X , with the licence number: 58606 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 674292 . This is a "NCPPO" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
• Identifier: 036101900 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
• Identifier: 243937 . This is a "KAISER" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
• Identifier: 3627348 . This is a "AETNA HMO" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
• Identifier: 7262589 . This is a "AETNA NONHMO" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
• Identifier: 0157 . This is a "CAREFIRST BCBS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
• Identifier: 010119600 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
• Identifier: 144796 . This is a "ANTHEM BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
• Identifier: 002045100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
• Identifier: 2126003 . This is a "MAMSI" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".