Provider Demographics
NPI:1447457452
Name:HALVORSON, AMI RENEE (OD)
Entity type:Individual
Prefix:DR
First Name:AMI
Middle Name:RENEE
Last Name:HALVORSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:360-242-3010
Mailing Address - Fax:
Practice Address - Street 1:1331 NW LOVEJOY ST STE 750
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3281
Practice Address - Country:US
Practice Address - Phone:503-535-2883
Practice Address - Fax:503-535-2887
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00004138152W00000X
OR3218ATI152W00000X
WAOD4138152W00000X
ORATI3218152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8934638OtherMEDICARE WA
WAG8934639OtherMEDICARE WA
WAG8934640OtherMEDICARE WA
WAG8934636OtherMEDICARE WA
WA2040883Medicaid
OR500609625Medicaid
WAG8934637OtherMEDICARE WA
ORR177569OtherMEDICARE OR