Provider Demographics
NPI:1033152277
Name:HALLENBECK, JOHN P (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:HALLENBECK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 RXR PLZ FL 13
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11556-1301
Mailing Address - Country:US
Mailing Address - Phone:516-453-0435
Mailing Address - Fax:
Practice Address - Street 1:350 BOULEVARD
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-2840
Practice Address - Country:US
Practice Address - Phone:973-365-4489
Practice Address - Fax:973-916-2032
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB70972207P00000X
NY284860207P00000X
NJ25MB07097200207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8777705Medicaid
NJ223586664OtherTRICARE/CHAMPUS
NJ223586664OtherBCBS
NJ8777705Medicaid
H35322Medicare UPIN
NJ047356Medicare ID - Type Unspecified