Provider Demographics
NPI:1972506368
Name:HALL, JON ROGER (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:ROGER
Last Name:HALL
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 1:755 S TELSHOR BLVD
Mailing Address - Street 2:STE 101C
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4644
Mailing Address - Country:US
Mailing Address - Phone:575-522-3393
Mailing Address - Fax:
Practice Address - Street 1:755 S TELSHOR BLVD
Practice Address - Street 2:STE 101C
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4644
Practice Address - Country:US
Practice Address - Phone:575-522-3393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001-205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
32605OtherCIGNA/LOVELACE
NMNM009780OtherBLUE CROSS/BLUE SHEILD
A36327Medicare UPIN
NM180042906Medicare ID - Type UnspecifiedRAILROAD MEDICARE
32605OtherCIGNA/LOVELACE