Basic Information
Provider Information
NPI: 1003804063
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HALLER
FirstName: JOHN
MiddleName: LLOYD
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1500 E 2ND ST
Address2: SUITE 206
City: RENO
State: NV
PostalCode: 895021181
CountryCode: US
TelephoneNumber: 7757897000
FaxNumber: 7757897040
Practice Location
Address1: 1500 E 2ND ST
Address2: SUITE 206
City: RENO
State: NV
PostalCode: 895021181
CountryCode: US
TelephoneNumber: 7757897000
FaxNumber: 7757897040
Other Information
ProviderEnumerationDate: 10/12/2005
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: X
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208600000X5729NVY Allopathic & Osteopathic PhysiciansSurgery 

ID Information
IDTypeStateIssuerDescription
XPY18723205CA MEDICAID
CC436901 BCBSOTHER


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