Provider Demographics
NPI:1083614721
Name:HALLIBURTON, CHARLES RAY JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RAY
Last Name:HALLIBURTON
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:7777 HENNESSY BLVD
Mailing Address - Street 2:SUITE 7000
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4300
Mailing Address - Country:US
Mailing Address - Phone:225-765-8829
Mailing Address - Fax:225-765-8283
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:SUITE 7000
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-765-8829
Practice Address - Fax:225-765-8283
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA10938R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1656500Medicaid
LA110110126OtherRAILROAD MEDICARE
LA1656500Medicaid
LAF99522Medicare UPIN
LA1656500Medicaid