Provider Demographics
NPI:1669967188
Name:HAVERKAMP, NATHAN (OD)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:
Last Name:HAVERKAMP
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18715 WILLOW SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-7997
Mailing Address - Country:US
Mailing Address - Phone:218-849-5952
Mailing Address - Fax:
Practice Address - Street 1:3001 WHITE BEAR AVE N STE 150
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1215
Practice Address - Country:US
Practice Address - Phone:651-770-3923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3576152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist