Provider Demographics
NPI:1528188596
Name:HALVERSON, DEWAYNE (OD)
Entity Type:Individual
Prefix:
First Name:DEWAYNE
Middle Name:
Last Name:HALVERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3744 LAKE OTIS PKWY
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3744 LAKE OTIS PKWY
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5208
Practice Address - Country:US
Practice Address - Phone:907-561-5118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4352152W00000X
AK061152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOP0061Medicaid