Provider Demographics
NPI:1982677852
Name:HALLIN, GUSTAV W (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAV
Middle Name:W
Last Name:HALLIN
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 1:1010 THREE SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-8296
Mailing Address - Country:US
Mailing Address - Phone:970-247-4311
Mailing Address - Fax:
Practice Address - Street 1:1010 THREE SPRINGS BLVD
Practice Address - Street 2:STE 110
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-8296
Practice Address - Country:US
Practice Address - Phone:970-764-2750
Practice Address - Fax:970-764-2778
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR-38630207RC0200X, 207RP1001X
CO38630207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO98285050Medicaid
C9804Medicare ID - Type Unspecified
F85873Medicare UPIN