Basic Information
| Provider Information | |||||||||
| NPI: | 1073507026 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VON HAAG | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2202 N FORBES BLVD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857451412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203961370 | ||||||||
| FaxNumber: | 5203961375 | ||||||||
| Practice Location | |||||||||
| Address1: | 4892 N STONE AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857045761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203961370 | ||||||||
| FaxNumber: | 5203961375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 10/10/2011 | ||||||||
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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 | 208G00000X | 32835 | AZ | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 867898 | 05 | AZ | MEDICAID |