Provider Demographics
NPI:1902809528
Name:HALLADAY, KIM A (DPM)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:A
Last Name:HALLADAY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2356 N 400 E
Mailing Address - Street 2:STE 104
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-3409
Mailing Address - Country:US
Mailing Address - Phone:435-882-0711
Mailing Address - Fax:435-882-1778
Practice Address - Street 1:2356 N 400 E
Practice Address - Street 2:STE 104
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-3409
Practice Address - Country:US
Practice Address - Phone:435-882-0711
Practice Address - Fax:435-882-1778
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT103966-0501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0994190001OtherDME
UT480008495OtherRAILROAD MEDICARE
UTQM0000054283OtherALTIUS
UT107006704101OtherIHC
UT2649OtherPEHP
UT870406457 84074OtherTRICARE
UT36338OtherDMBA
UT870406457 HA1OtherEMIA
UTQM0000054283OtherALTIUS
UT480008495OtherRAILROAD MEDICARE