Healthcare Provider Details

I. General information

NPI: 1639193360
Provider Name (Legal Business Name): DONALD O HALL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7487 S STATE ROAD 121 NORTHEAST FLORIDA STATE HOSPITAL
MACCLENNY FL
32063-5451
US

IV. Provider business mailing address

820 PRUDENTIAL DR STE 713
JACKSONVILLE FL
32207-8209
US

V. Phone/Fax

Practice location:
  • Phone: 904-396-5682
  • Fax: 904-346-0864
Mailing address:
  • Phone: 904-396-5682
  • Fax: 904-346-0864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS2329
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: