Provider Demographics
NPI:1255331757
Name:HALLBERG, THEODORE M (OD)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:M
Last Name:HALLBERG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:MR
Other - First Name:THEODORE
Other - Middle Name:M
Other - Last Name:HALLBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3206 CHURCHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-5206
Mailing Address - Country:US
Mailing Address - Phone:757-484-0101
Mailing Address - Fax:757-484-0515
Practice Address - Street 1:3206 CHURCHLAND BLVD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-5206
Practice Address - Country:US
Practice Address - Phone:757-484-0101
Practice Address - Fax:757-484-0515
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0601002124152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009235094Medicaid
VA753028236OtherTAX ID#
VA009235094Medicaid
VAU74062Medicare UPIN
VA410048943Medicare ID - Type UnspecifiedRAILROAD