Provider Demographics
NPI:1841633187
Name:HALLOCK, JUSTIN DAVID
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DAVID
Last Name:HALLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 16TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-3595
Mailing Address - Country:US
Mailing Address - Phone:256-350-0362
Mailing Address - Fax:256-350-0363
Practice Address - Street 1:1103 16TH AVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-3595
Practice Address - Country:US
Practice Address - Phone:256-350-0362
Practice Address - Fax:256-350-0363
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL38103207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine