Basic Information
| Provider Information | |||||||||
| NPI: | 1134357338 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAFFORD | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | GLENN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S EUCLID AVE | ||||||||
| Address2: | MSC 8242-22-02 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143628200 | ||||||||
| FaxNumber: | 8332105713 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 N MASON RD | ||||||||
| Address2: | DIV SURG UROLOGY | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631416399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143628200 | ||||||||
| FaxNumber: | 8332105713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2009 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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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 | 363AS0400X | 2019043868 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 220090113 | 05 | MO | MEDICAID |