Basic Information
| Provider Information | |||||||||
| NPI: | 1114016342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HALVERSON | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 S NATIONAL AVE | ||||||||
| Address2: | #540 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172698825 | ||||||||
| FaxNumber: | 4172698744 | ||||||||
| Practice Location | |||||||||
| Address1: | 1423 N JEFFERSON AVE | ||||||||
| Address2: | #B100 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658021917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172698825 | ||||||||
| FaxNumber: | 4172698744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 01/07/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R6217 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 22024 | 01 | MO | BCMO | OTHER | 200212926 | 05 | MO | MEDICAID |