Healthcare Provider Details

I. General information

NPI: 1740286970
Provider Name (Legal Business Name): GARY L HALVERSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 E 3900 S #B150
SALT LAKE CITY UT
84124-1216
US

IV. Provider business mailing address

1151 E 3900 S #B150
SALT LAKE CITY UT
84124-1216
US

V. Phone/Fax

Practice location:
  • Phone: 801-262-3441
  • Fax: 801-269-9005
Mailing address:
  • Phone: 801-262-3441
  • Fax: 801-269-9005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number1619861205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: