Provider Demographics
NPI:1396740338
Name:HALT, PETER SPELLMAN (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:SPELLMAN
Last Name:HALT
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 1086
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-1086
Mailing Address - Country:US
Mailing Address - Phone:530-842-7297
Mailing Address - Fax:
Practice Address - Street 1:914 PINE ST
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2143
Practice Address - Country:US
Practice Address - Phone:530-926-9329
Practice Address - Fax:530-926-9855
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2017-10-04
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
CAA76207247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A762070Medicaid
CAH79959Medicare UPIN
CA00A762070Medicare ID - Type Unspecified