Provider Demographics
NPI:1811058415
Name:HALLAK, ANTOINE (MD)
Entity type:Individual
Prefix:
First Name:ANTOINE
Middle Name:
Last Name:HALLAK
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 1:16766 BERNARDO CENTER DR
Mailing Address - Street 2:SUITE 109
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2501
Mailing Address - Country:US
Mailing Address - Phone:858-592-9200
Mailing Address - Fax:858-592-9218
Practice Address - Street 1:16766 BERNARDO CENTER DR
Practice Address - Street 2:SUITE 109
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128
Practice Address - Country:US
Practice Address - Phone:858-592-9200
Practice Address - Fax:858-592-9218
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87305208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A873050Medicaid
CAWA87305AMedicare ID - Type Unspecified
CAY29346Medicare UPIN