Basic Information
| Provider Information | |||||||||
| NPI: | 1710963855 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALBACH | ||||||||
| FirstName: | VAN | ||||||||
| MiddleName: | V. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT LA 23407 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911850001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4153531869 | ||||||||
| FaxNumber: | 4153538606 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 PARNASSUS AVE | ||||||||
| Address2: | L352 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941432204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4153531869 | ||||||||
| FaxNumber: | 4153538606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 05/14/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G47701 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0026390 | 05 | CA | MEDICAID |