Provider Demographics
NPI:1760469563
Name:HALLENBECK, JONATHAN J (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:J
Last Name:HALLENBECK
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:PO BOX 1849
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04241-1849
Mailing Address - Country:US
Mailing Address - Phone:207-784-2554
Mailing Address - Fax:207-777-1439
Practice Address - Street 1:149 NORTH ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4974
Practice Address - Country:US
Practice Address - Phone:207-872-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0127452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E21246Medicare UPIN