Provider Demographics
NPI:1467542167
Name:HALSTED, GWENDOLYN ALICE (MD)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:ALICE
Last Name:HALSTED
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374
Mailing Address - Country:US
Mailing Address - Phone:765-973-9294
Mailing Address - Fax:765-973-9233
Practice Address - Street 1:203 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374
Practice Address - Country:US
Practice Address - Phone:765-973-9294
Practice Address - Fax:765-973-9233
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035332A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100321430AMedicaid
IN100321430AMedicaid
IN905170BMedicare PIN