Provider Demographics
NPI:1104150804
Name:HALBACH, JONATHAN L (DO)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:L
Last Name:HALBACH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 JOHN PAUL JONES CIR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23708-2111
Mailing Address - Country:US
Mailing Address - Phone:757-953-2433
Mailing Address - Fax:
Practice Address - Street 1:NMRTC PORTSMOUTH
Practice Address - Street 2:620 JOHN PAUL JONES CIRCLE
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708
Practice Address - Country:US
Practice Address - Phone:757-953-2446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-28
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01022072832086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery