Provider Demographics
NPI:1548417470
Name:HALLAQ, ISSA Y (DO)
Entity Type:Individual
Prefix:
First Name:ISSA
Middle Name:Y
Last Name:HALLAQ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 W WETMORE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-1687
Mailing Address - Country:US
Mailing Address - Phone:520-293-4683
Mailing Address - Fax:520-293-4683
Practice Address - Street 1:1 W WETMORE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-1687
Practice Address - Country:US
Practice Address - Phone:520-293-4683
Practice Address - Fax:520-293-4683
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-21
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ0834207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZC98252Medicare UPIN