Provider Demographics
NPI:1023007044
Name:O'HALLORAN, LAURENCE R (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:R
Last Name:O'HALLORAN
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 1:3299 WOODBURN RD
Mailing Address - Street 2:#300
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-1275
Mailing Address - Country:US
Mailing Address - Phone:703-534-3314
Mailing Address - Fax:703-698-1334
Practice Address - Street 1:3299 WOODBURN RD
Practice Address - Street 2:#300
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-1275
Practice Address - Country:US
Practice Address - Phone:703-534-3314
Practice Address - Fax:703-698-1334
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051134174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA65-022-11Medicaid
VAH412293Medicare ID - Type UnspecifiedPROVIDER #
VA65-022-11Medicaid