Provider Demographics
NPI:1114016342
Name:HALVERSON, LARRY W (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:W
Last Name:HALVERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3800 S NATIONAL AVE
Mailing Address - Street 2:#540
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5209
Mailing Address - Country:US
Mailing Address - Phone:417-269-8825
Mailing Address - Fax:417-269-8744
Practice Address - Street 1:1423 N JEFFERSON AVE
Practice Address - Street 2:#B100
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-1917
Practice Address - Country:US
Practice Address - Phone:417-269-8825
Practice Address - Fax:417-269-8744
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR6217207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO22024OtherBCMO
MO200212926Medicaid
MO22024OtherBCMO
A14133Medicare UPIN
MO200212926Medicaid