Provider Demographics
NPI:1376575423
Name:HALL, JOHN E
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:HALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 350
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-0350
Mailing Address - Country:US
Mailing Address - Phone:262-723-2234
Mailing Address - Fax:226-723-2834
Practice Address - Street 1:419 N WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-1317
Practice Address - Country:US
Practice Address - Phone:262-723-2234
Practice Address - Fax:226-723-2834
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1349152W00000X
IL046006337152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38571300Medicaid
T62103Medicare UPIN
WI87714Medicare ID - Type Unspecified
87714Medicare PIN
WI38571300Medicaid