Provider Demographics
NPI:1407843469
Name:HALSTEAD, DAVID RALPH (DPM)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:RALPH
Last Name:HALSTEAD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 HOLLYWOOD RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8510
Mailing Address - Country:US
Mailing Address - Phone:269-428-2440
Mailing Address - Fax:269-428-0980
Practice Address - Street 1:3800 HOLLYWOOD RD
Practice Address - Street 2:SUITE 103
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8510
Practice Address - Country:US
Practice Address - Phone:269-428-2440
Practice Address - Fax:269-428-0980
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDH001838213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M09030004Medicare ID - Type Unspecified
MIU71011Medicare UPIN