Basic Information
| Provider Information | |||||||||
| NPI: | 1902899016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALVERSON | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HALVERSON | ||||||||
| OtherFirstName: | J | ||||||||
| OtherMiddleName: | MATTHEW | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11835 FISHING POINT DR | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236062584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575995588 | ||||||||
| FaxNumber: | 7575996893 | ||||||||
| Practice Location | |||||||||
| Address1: | 11835 FISHING POINT DR | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236062584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575995588 | ||||||||
| FaxNumber: | 7575996893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 04/25/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/27/2006 | ||||||||
| NPIReactivationDate: | 04/13/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS15143 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0102049844 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00Y043J02 | 01 | VA | MEDICARE PTAN | OTHER | C10736 | 01 | GROUP PTN | OTHER | 1902899016 | 05 | VA | MEDICAID |