Provider Demographics
NPI:1700137262
Name:HALL, DAVE A (MS SPEC/GEN ED)
Entity Type:Individual
Prefix:MR
First Name:DAVE
Middle Name:A
Last Name:HALL
Suffix:
Gender:M
Credentials:MS SPEC/GEN ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2071 FLATBUSH AVE APT 198
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4340
Mailing Address - Country:US
Mailing Address - Phone:718-790-0500
Mailing Address - Fax:
Practice Address - Street 1:2071 FLATBUSH AVE
Practice Address - Street 2:198
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4340
Practice Address - Country:US
Practice Address - Phone:718-790-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2290841174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY53200Medicaid