Provider Demographics
NPI:1720004799
Name:HALLETT, ROBERT VICTOR (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:VICTOR
Last Name:HALLETT
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 1:1113 ELLIS AVE
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3346
Mailing Address - Country:US
Mailing Address - Phone:936-899-7184
Mailing Address - Fax:936-899-7023
Practice Address - Street 1:1113 ELLIS AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3346
Practice Address - Country:US
Practice Address - Phone:936-899-7184
Practice Address - Fax:936-899-7203
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9581207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171970001Medicaid
TX172328004Medicaid
TX0054LXOtherBCBS
TXDD0066OtherRAILROAD MEDICARE
TXTXB148821Medicare PIN
TX00498YMedicare PIN
B12801Medicare UPIN