Provider Demographics
NPI:1407925597
Name:ANTOINE HALLAK MD, INC
Entity Type:Organization
Organization Name:ANTOINE HALLAK MD, INC
Other - Org Name:SAN DIEGO INSTITUTE OF PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTOINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-592-9200
Mailing Address - Street 1:16766 BERNARDO CENTER DR
Mailing Address - Street 2:SUITE 109
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2545
Mailing Address - Country:US
Mailing Address - Phone:858-592-9200
Mailing Address - Fax:858-592-9218
Practice Address - Street 1:16766 BERNARDO CENTER DR
Practice Address - Street 2:SUITE 109
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2545
Practice Address - Country:US
Practice Address - Phone:858-592-9200
Practice Address - Fax:858-592-9218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87305208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18521Medicare ID - Type Unspecified