Provider Demographics
NPI:1417068115
Name:HALIBURTON, BRYANT (MD)
Entity type:Individual
Prefix:
First Name:BRYANT
Middle Name:
Last Name:HALIBURTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11510 GEORGIA AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WHEATON
Mailing Address - State:MD
Mailing Address - Zip Code:20902-1925
Mailing Address - Country:US
Mailing Address - Phone:301-946-5100
Mailing Address - Fax:301-929-0348
Practice Address - Street 1:110 IRVING ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2976
Practice Address - Country:US
Practice Address - Phone:301-946-5100
Practice Address - Fax:301-929-0348
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD034253207L00000X
PAMD428012207L00000X
GA58606207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC674292OtherNCPPO
DC036101900Medicaid
DC243937OtherKAISER
DC3627348OtherAETNA HMO
DC7262589OtherAETNA NONHMO
DC0157OtherCAREFIRST BCBS
VA010119600Medicaid
VA144796OtherANTHEM BCBS
MD002045100Medicaid
DC2126003OtherMAMSI
DC0157OtherCAREFIRST BCBS
I21425Medicare UPIN
DC036101900Medicaid