Provider Demographics
NPI:1902121742
Name:HALVERSON, BRYAN (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
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 1:11234 ANDERSON ST
Mailing Address - Street 2:GME OFFICE CP 21005
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:GRADUATE MEDICAL EDUCATION OFFICE CP 21005
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-8131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-05
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA114170207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology