Provider Demographics
NPI:1902074990
Name:HALLETT HEART PA
Entity Type:Organization
Organization Name:HALLETT HEART PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:HALLETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-631-3045
Mailing Address - Street 1:1113 ELLIS AVE
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3346
Mailing Address - Country:US
Mailing Address - Phone:936-899-7184
Mailing Address - Fax:936-899-7203
Practice Address - Street 1:1113 ELLIS AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3346
Practice Address - Country:US
Practice Address - Phone:936-899-7184
Practice Address - Fax:936-899-7203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0054LXOtherBC
TX171970001Medicaid
TXDD0066OtherRAILROAD MEDICARE
TXDD0066OtherRAILROAD MEDICARE