Healthcare Provider Details

I. General information

NPI: 1417068115
Provider Name (Legal Business Name): BRYANT HALIBURTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/11/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 IRVING ST NW
WASHINGTON DC
20010-2976
US

IV. Provider business mailing address

11510 GEORGIA AVE SUITE 206
WHEATON MD
20902-1925
US

V. Phone/Fax

Practice location:
  • Phone: 301-946-5100
  • Fax: 301-929-0348
Mailing address:
  • Phone: 301-946-5100
  • Fax: 301-929-0348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD034253
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD428012
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number58606
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: