Provider Demographics
NPI:1023171691
Name:HALL, WILLIAM R (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
Last Name:HALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:702 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-5705
Mailing Address - Country:US
Mailing Address - Phone:505-632-8088
Mailing Address - Fax:505-632-3805
Practice Address - Street 1:702 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-5705
Practice Address - Country:US
Practice Address - Phone:505-632-8088
Practice Address - Fax:505-632-3805
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM471152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000Q5854Medicaid
NM000Q5854Medicaid
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