=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255331757
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEODORE M HALLBERG OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2005
-----------------------------------------------------
Last Update Date | 07/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3206 CHURCHLAND BLVD
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23321-5206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-484-0101
-----------------------------------------------------
Fax | 757-484-0515
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3206 CHURCHLAND BLVD
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23321-5206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-484-0101
-----------------------------------------------------
Fax | 757-484-0515
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 0601002124
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------