Provider Demographics
NPI:1922007343
Name:HALLBAUER, GREGG M (DO)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:M
Last Name:HALLBAUER
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 1:4015 INTERSTATE 45 N
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-4901
Mailing Address - Country:US
Mailing Address - Phone:936-756-6631
Mailing Address - Fax:
Practice Address - Street 1:4015 INTERSTATE 45 N
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-4901
Practice Address - Country:US
Practice Address - Phone:936-756-6631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2299207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148219205Medicaid
TX00J21AOtherGROUP MEDICARE NUMBER
TX148219205Medicaid
TX00J21AOtherGROUP MEDICARE NUMBER