Provider Demographics
NPI:1619175890
Name:HALVERSON, MARK ROLLO (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROLLO
Last Name:HALVERSON
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 1:816 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3146
Mailing Address - Country:US
Mailing Address - Phone:817-321-0387
Mailing Address - Fax:
Practice Address - Street 1:816 W CANNON ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3146
Practice Address - Country:US
Practice Address - Phone:817-321-0387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4457982085P0229X
TXP87852085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX285250104Medicaid
TX121715004Medicaid
TX121715008Medicaid
TXTXB120692Medicare PIN
TXTXB120694Medicare PIN
TX00JO62Medicare PIN