Basic Information
| Provider Information | |||||||||
| NPI: | 1235767153 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALSTED | ||||||||
| FirstName: | DECOTA | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HALSTED | ||||||||
| OtherFirstName: | CODY | ||||||||
| OtherMiddleName: | MATTHEW | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 72 BLAIR DR | ||||||||
| Address2: | |||||||||
| City: | VILONIA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721738045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5014993058 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4301 W MARKHAM ST # 589 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722057101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5015268148 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2020 | ||||||||
| LastUpdateDate: | 03/27/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.