Provider Demographics
NPI:1902899016
Name:HALVERSON, JAMES MATTHEW (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MATTHEW
Last Name:HALVERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:J
Other - Middle Name:MATTHEW
Other - Last Name:HALVERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:11835 FISHING POINT DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-2584
Mailing Address - Country:US
Mailing Address - Phone:757-599-5588
Mailing Address - Fax:757-599-6893
Practice Address - Street 1:11835 FISHING POINT DR
Practice Address - Street 2:SUITE 104
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2584
Practice Address - Country:US
Practice Address - Phone:757-599-5588
Practice Address - Fax:757-599-6893
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2019-04-25
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-13
Provider Licenses
StateLicense IDTaxonomies
FLOS15143207Q00000X
VA0102049844207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00Y043J02OtherMEDICARE PTAN
C10736OtherGROUP PTN
VA1902899016Medicaid