MEDICARE: DEWAYNE HALVERSON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4352	CA
2	152W00000X	Optometrist	061	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528188596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEWAYNE HALVERSON O.D.

Provider Business Mailing Address
First Line	:	3744 LAKE OTIS PKWY
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-5208
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3744 LAKE OTIS PKWY
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-5208
Country	:	US
Telephone Number	:	907-561-5118
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2007
Last Update Date	:	07/09/2007

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