Provider Demographics
NPI:1407819832
Name:HALAND, THEODORE J (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:J
Last Name:HALAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 CURVE CREST BLVD W
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6040
Mailing Address - Country:US
Mailing Address - Phone:651-439-1234
Mailing Address - Fax:651-439-1547
Practice Address - Street 1:1500 CURVE CREST BLVD W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6040
Practice Address - Country:US
Practice Address - Phone:651-439-1234
Practice Address - Fax:651-351-0827
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46742207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34853500Medicaid
MN080015051Medicare PIN
I19457Medicare UPIN
WI34853500Medicaid