Healthcare Provider Details

I. General information

NPI: 1972506368
Provider Name (Legal Business Name): JON ROGER HALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 S TELSHOR BLVD STE 101C
LAS CRUCES NM
88011-4644
US

IV. Provider business mailing address

755 S TELSHOR BLVD STE 101C
LAS CRUCES NM
88011-4644
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-3393
  • Fax:
Mailing address:
  • Phone: 575-522-3393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2001-205
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: