Provider Demographics
NPI:1588754873
Name:HALVORSON, GLEN ALLEN (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:ALLEN
Last Name:HALVORSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 E BELL RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-9306
Mailing Address - Country:US
Mailing Address - Phone:602-795-3649
Mailing Address - Fax:602-795-3996
Practice Address - Street 1:4550 E BELL RD
Practice Address - Street 2:SUITE 150
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-9306
Practice Address - Country:US
Practice Address - Phone:602-795-3649
Practice Address - Fax:602-795-3996
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75477208100000X
CO47769208100000X
NV13342208100000X
AZ13423208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ235780OtherAHCCCS