Provider Demographics
NPI:1972577823
Name:HALLER, HAROLD DALE JR (MD)
Entity type:Individual
Prefix:
First Name:HAROLD
Middle Name:DALE
Last Name:HALLER
Suffix:JR
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 1:4003 KRESGE WAY
Mailing Address - Street 2:STE 312
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207
Mailing Address - Country:US
Mailing Address - Phone:502-899-7377
Mailing Address - Fax:502-899-1972
Practice Address - Street 1:4003 KRESGE WAY STE 312
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4652
Practice Address - Country:US
Practice Address - Phone:502-899-7377
Practice Address - Fax:502-899-1972
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31062207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1079140OtherPASSPORT
KY64310626Medicaid
KY290012790OtherRR MEDICARE
KY0548905Medicare PIN
KY1079140OtherPASSPORT