Provider Demographics
NPI:1467500686
Name:HALLISEY, JOHN WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
Last Name:HALLISEY
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 1:1270 PEACH ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2856
Mailing Address - Country:US
Mailing Address - Phone:805-541-1342
Mailing Address - Fax:805-541-5836
Practice Address - Street 1:1270 PEACH ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2856
Practice Address - Country:US
Practice Address - Phone:805-541-1342
Practice Address - Fax:805-541-5836
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25366207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G253660Medicaid
CAWG25366EMedicare ID - Type UnspecifiedSANTA MARIA
CAWG25366AMedicare ID - Type UnspecifiedSAN LUIS OBISPO
CAA42636Medicare UPIN
CA00G253660Medicaid
CAWG25366CMedicare ID - Type UnspecifiedCAMBRIA
CAWG25366DMedicare ID - Type UnspecifiedTEMPLETON