Provider Demographics
NPI:1740234996
Name:HALVORSON, DEREK S (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:S
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:PO BOX 5037
Mailing Address - Street 2:UNIT 282
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-5037
Mailing Address - Country:US
Mailing Address - Phone:360-514-2142
Mailing Address - Fax:360-514-6820
Practice Address - Street 1:600 NE 92ND AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-3225
Practice Address - Country:US
Practice Address - Phone:360-514-2142
Practice Address - Fax:360-514-6820
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043686207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8398398Medicaid
OR278165Medicaid
WA8398398Medicaid
WAI08957Medicare UPIN