1902899016 NPI number — JAMES MATTHEW HALVERSON DO

Table of content: JAMES MATTHEW HALVERSON DO (NPI 1902899016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902899016 NPI number — JAMES MATTHEW HALVERSON DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HALVERSON
Provider First Name:
JAMES
Provider Middle Name:
MATTHEW
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HALVERSON
Provider Other First Name:
J
Provider Other Middle Name:
MATTHEW
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1902899016
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/27/2006
NPI Reactivation Date:
04/13/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11835 FISHING POINT DR
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
NEWPORT NEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23606-2584
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-599-5588
Provider Business Mailing Address Fax Number:
757-599-6893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11835 FISHING POINT DR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
NEWPORT NEWS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23606-2584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-599-5588
Provider Business Practice Location Address Fax Number:
757-599-6893
Provider Enumeration Date:
08/24/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  OS15143 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 0102049844 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00Y043J02 . This is a "MEDICARE PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: C10736 . This is a "GROUP PTN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1902899016 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102336800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".