Provider Demographics
NPI:1235354457
Name:HALLETT, VICTORIA (DO)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:HALLETT
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 1:212 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:MI
Mailing Address - Zip Code:49230-9114
Mailing Address - Country:US
Mailing Address - Phone:517-592-6047
Mailing Address - Fax:517-787-0730
Practice Address - Street 1:212 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MI
Practice Address - Zip Code:49230-9114
Practice Address - Country:US
Practice Address - Phone:517-592-6047
Practice Address - Fax:517-787-0730
Is Sole Proprietor?:No
Enumeration Date:2007-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700C86065OtherBLUE CROSS
MIE91166Medicare UPIN