Provider Demographics
NPI:1033162425
Name:HALDEMAN, TRAVIS (DO)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:HALDEMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S LAKE PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-6638
Mailing Address - Country:US
Mailing Address - Phone:219-947-6153
Mailing Address - Fax:219-703-6501
Practice Address - Street 1:3545 ARBOR BLVD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-4298
Practice Address - Country:US
Practice Address - Phone:708-636-9205
Practice Address - Fax:708-229-6075
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004689A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201321810Medicaid
ILH12485Medicare UPIN
ILL77263Medicare ID - Type Unspecified