Provider Demographics
NPI:1881613495
Name:HAVERTAPE, MARK ALLAN (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLAN
Last Name:HAVERTAPE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3804 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5603
Mailing Address - Country:US
Mailing Address - Phone:319-364-6387
Mailing Address - Fax:
Practice Address - Street 1:3804 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5603
Practice Address - Country:US
Practice Address - Phone:319-364-6387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA05832111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0125369Medicaid
IAI5951Medicare ID - Type UnspecifiedCHIROPRACTRIC