Provider Demographics
NPI:1558937847
Name:HALLAWAY, BRANDON WALTER (DO)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:WALTER
Last Name:HALLAWAY
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 1:9202 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2458
Mailing Address - Country:US
Mailing Address - Phone:602-786-1024
Mailing Address - Fax:
Practice Address - Street 1:9201 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2532
Practice Address - Country:US
Practice Address - Phone:480-882-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR3620390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program