Provider Demographics
NPI:1578555264
Name:HALVORSON, THOMAS LEE (MD)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:LEE
Last Name:HALVORSON
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 1:723 MEMORIAL STREET
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350
Mailing Address - Country:US
Mailing Address - Phone:509-786-2222
Mailing Address - Fax:509-786-6612
Practice Address - Street 1:820 MEMORIAL STREET
Practice Address - Street 2:STE 3
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350
Practice Address - Country:US
Practice Address - Phone:509-786-5599
Practice Address - Fax:509-788-0488
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM12512207X00000X
IDTLM-4023207X00000X
WAMD00037662207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8244063Medicaid
E16698Medicare UPIN
WAAB10767Medicare ID - Type Unspecified