Provider Demographics
NPI:1407941636
Name:HALLIWELL, TERESA (OD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:
Last Name:HALLIWELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1859 NEWBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-2218
Mailing Address - Country:US
Mailing Address - Phone:516-785-4483
Mailing Address - Fax:
Practice Address - Street 1:1859 NEWBRIDGE RD
Practice Address - Street 2:
Practice Address - City:NORTH BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-2218
Practice Address - Country:US
Practice Address - Phone:516-785-4483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0044191152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC40321Medicare PIN