Provider Demographics
NPI:1558451708
Name:HALSTED, CHARLES H (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:H
Last Name:HALSTED
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 1:451 HEALTH SCIENCES DR.
Mailing Address - Street 2:5303 GBSF
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616
Mailing Address - Country:US
Mailing Address - Phone:530-752-6778
Mailing Address - Fax:
Practice Address - Street 1:2825 J ST
Practice Address - Street 2:SUITE 300
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-4300
Practice Address - Country:US
Practice Address - Phone:916-734-2890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207REO10X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00392OtherPI NUMBER
CAG026076OtherSTATE LICENSE
CAG026076OtherSTATE LICENSE
CAA42894Medicare UPIN