Basic Information
| Provider Information | |||||||||
| NPI: | 1487640397 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HALPERN | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 732901 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753732901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862264590 | ||||||||
| FaxNumber: | 3862263371 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 BOOTH RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321745715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3865231212 | ||||||||
| FaxNumber: | 3865231213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 06/06/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME124133 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 223250-1 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 64097124 | 05 | KY | MEDICAID | 000000359520 | 01 | IN | ANTHEM BC/BS | OTHER | BH7568376 | 01 | IN | DEA # | OTHER | 15D1038972 | 01 | IN | CLIA | OTHER | 200063730A | 05 | IN | MEDICAID |