Provider Demographics
NPI:1235767153
Name:HALSTED, DECOTA MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:DECOTA
Middle Name:MATTHEW
Last Name:HALSTED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CODY
Other - Middle Name:MATTHEW
Other - Last Name:HALSTED
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3401 WEST MARKHAM STREET
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205
Mailing Address - Country:US
Mailing Address - Phone:501-499-3058
Mailing Address - Fax:
Practice Address - Street 1:4301 W MARKHAM ST # 589
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-526-8148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-27
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-160982084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program