Provider Demographics
NPI:1407951452
Name:HALLER, MARLA G (DO)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:G
Last Name:HALLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-395-8805
Mailing Address - Fax:740-395-8855
Practice Address - Street 1:280 PATTONSVILLE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-9452
Practice Address - Country:US
Practice Address - Phone:740-395-8805
Practice Address - Fax:740-395-8855
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH34006023H207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000347352OtherANTHEM
OH310917085320OtherOHIO MEDICAID CARESOURCE
WV3810023943Medicaid
OH000000498993OtherOH MEDICAID UNISON
OH0994063Medicaid
OHHA7332591Medicare ID - Type Unspecified
OH310917085320OtherOHIO MEDICAID CARESOURCE
OHH121790Medicare PIN