Provider Demographics
NPI:1831297472
Name:MARK A. HAVERTAPE P.C.
Entity Type:Organization
Organization Name:MARK A. HAVERTAPE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:HAVERTAPE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:319-364-6387
Mailing Address - Street 1:3804 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5603
Mailing Address - Country:US
Mailing Address - Phone:319-364-6387
Mailing Address - Fax:
Practice Address - Street 1:3804 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5603
Practice Address - Country:US
Practice Address - Phone:319-364-6387
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA05832111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0125369Medicaid
IA0125369Medicaid