Healthcare Provider Details

I. General information

NPI: 1215694591
Provider Name (Legal Business Name): MARK LOUIS HALFMAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2021
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMR 411
APO AE
09112
US

IV. Provider business mailing address

4801 CAMPBELL ST
VALPARAISO IN
46385-1002
US

V. Phone/Fax

Practice location:
  • Phone: 314-599-1850
  • Fax:
Mailing address:
  • Phone: 314-599-1850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number02007415A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number02007415A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: