Provider Demographics
NPI:1366552143
Name:HALLER, CARL (MD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:
Last Name:HALLER
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 1:3609 MISSION AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-2955
Mailing Address - Country:US
Mailing Address - Phone:916-483-3437
Mailing Address - Fax:916-483-3218
Practice Address - Street 1:3609 MISSION AVE
Practice Address - Street 2:SUITE D
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-2955
Practice Address - Country:US
Practice Address - Phone:916-483-3437
Practice Address - Fax:916-483-3218
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG9581207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9581OtherMEDICAL LICENSE
CA000G95810Medicaid
CAG9581OtherMEDICAL LICENSE
000G95810Medicare ID - Type Unspecified