Provider Demographics
NPI:1508756032
Name:HALTOM, MATTHEW TYLER
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TYLER
Last Name:HALTOM
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16201 THORNCROWN LN
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-3257
Mailing Address - Country:US
Mailing Address - Phone:318-820-1071
Mailing Address - Fax:
Practice Address - Street 1:16201 THORNCROWN LN
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-3257
Practice Address - Country:US
Practice Address - Phone:318-820-1071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-07
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program