Healthcare Provider Details

I. General information

NPI: 1083614721
Provider Name (Legal Business Name): CHARLES RAY HALLIBURTON JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5228 DIJON DR
BATON ROUGE LA
70808-4311
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 225-765-8829
  • Fax: 225-765-8283
Mailing address:
  • Phone: 225-765-8829
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number10938R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: