Healthcare Provider Details

I. General information

NPI: 1033162425
Provider Name (Legal Business Name): TRAVIS HALDEMAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3545 ARBOR BLVD
PORTAGE IN
46368-4298
US

IV. Provider business mailing address

1500 S LAKE PARK AVE
HOBART IN
46342-6638
US

V. Phone/Fax

Practice location:
  • Phone: 708-636-9205
  • Fax: 708-229-6075
Mailing address:
  • Phone: 219-947-6153
  • Fax: 219-703-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number02004689A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: