Provider Demographics
NPI:1558446351
Name:HALLDORSON, JEFFREY BURKE (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:BURKE
Last Name:HALLDORSON
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 1:4225 EXECUTIVE SQ STE 450
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-8411
Mailing Address - Country:US
Mailing Address - Phone:858-810-0000
Mailing Address - Fax:858-268-1911
Practice Address - Street 1:8010 FROST ST STE 510
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4284
Practice Address - Country:US
Practice Address - Phone:858-637-4800
Practice Address - Fax:858-637-4801
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86089204F00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG86089OtherCA LICENSE
F89794Medicare UPIN
CAG86089OtherCA LICENSE
CAG86089OtherCA LICENSE