Provider Demographics
NPI:1861609778
Name:HALLAK, LAURA ARVILLA (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ARVILLA
Last Name:HALLAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ARVILLA
Other - Last Name:TAMAYO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1139
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-0228
Mailing Address - Country:US
Mailing Address - Phone:360-538-0135
Mailing Address - Fax:360-533-3475
Practice Address - Street 1:1921 SUMNER AVE
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-3606
Practice Address - Country:US
Practice Address - Phone:360-538-0135
Practice Address - Fax:360-533-3475
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57010092207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD60014640OtherMEDICAL LICENSE
WA1126192Medicaid
WA1126192Medicaid
G8875174Medicare PIN