Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204F00000X | Transplant Surgeon | G86089 | CA |
Y | 208200000X | Surgeon | G86089 | CA |
Y | 208600000X | Surgeon | G86089 | CA |
NPI | 1558446351 |
---|---|
Provider Name | Jeffrey Burke Halldorson |
First Address | La Jolla, CA 92037-8411 |
Second Address | San Diego, CA 92123-4284 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/10/2006 |
Last Update Date | 29/01/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F89794 | (02) | |
G86089 | CA LICENSE (01) | CA |