Healthcare Provider Details

I. General information

NPI: 1215938006
Provider Name (Legal Business Name): ROBERT M HALLIVIS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3998 FAIR RIDGE DR STE 280
FAIRFAX VA
22033-2907
US

IV. Provider business mailing address

3998 FAIR RIDGE DR STE 280
FAIRFAX VA
22033-2907
US

V. Phone/Fax

Practice location:
  • Phone: 703-849-8400
  • Fax: 703-849-8448
Mailing address:
  • Phone: 703-849-8400
  • Fax: 703-849-8448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103300812
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number0103300812
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: