Provider Demographics
NPI:1003989260
Name:HAVLAK, DIRK FRANCIS (MD)
Entity type:Individual
Prefix:DR
First Name:DIRK
Middle Name:FRANCIS
Last Name:HAVLAK
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 1:1613 CAMDEN CIR SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98512-5552
Mailing Address - Country:US
Mailing Address - Phone:360-943-2734
Mailing Address - Fax:
Practice Address - Street 1:5130 CORPORATE CENTER CT SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5957
Practice Address - Country:US
Practice Address - Phone:360-413-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020629207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8546905Medicaid
WAAH9552591OtherDEA
WAAB20314Medicare UPIN
WA8546905Medicaid