Healthcare Provider Details

I. General information

NPI: 1821679077
Provider Name (Legal Business Name): JOHN ROWE HALLSTEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/19/2021
Certification Date: 04/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 GILMAN DR
LA JOLLA CA
92093-5004
US

IV. Provider business mailing address

3380 SIERRA OAKS DR
SACRAMENTO CA
95864-5729
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-7404
  • Fax:
Mailing address:
  • Phone: 916-915-2226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: