Provider Demographics
NPI:1104830595
Name:HALVORSEN, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HALVORSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 WASHINGTON AVE SE
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414
Mailing Address - Country:US
Mailing Address - Phone:612-884-0649
Mailing Address - Fax:
Practice Address - Street 1:1414 MARYLAND AVE E
Practice Address - Street 2:UMPHYSICIANS PHALEN VILLAGE CLINIC
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106
Practice Address - Country:US
Practice Address - Phone:651-772-3461
Practice Address - Fax:651-772-5477
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20514207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL025128OtherHEALTH ALLIANCE
IL472301OtherHEALTHLINK
IL080154707OtherRAILROAD MEDICARE
ILIL01P7OtherJOHN DEERE
IL0360893132Medicaid
IL7215059OtherBCBS PPO
IL025128OtherHEALTH ALLIANCE
ILK02954Medicare ID - Type Unspecified