Provider Demographics
NPI:1114915402
Name:HALLGREN, SALLY ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:ANN
Last Name:HALLGREN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-1924
Mailing Address - Country:US
Mailing Address - Phone:817-877-4787
Mailing Address - Fax:817-877-1654
Practice Address - Street 1:311 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-1924
Practice Address - Country:US
Practice Address - Phone:817-877-4787
Practice Address - Fax:817-877-1654
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9484207LP2900X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0325318-01Medicaid
TX0325318-01Medicaid
TXD97364Medicare UPIN