Basic Information
Provider Information | |||||||||
NPI: | 1164517074 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAUN | ||||||||
FirstName: | LORI | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MILLERHAUN | ||||||||
OtherFirstName: | LORI | ||||||||
OtherMiddleName: | ELLEN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | OD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | S2845 WHITE EAGLE RD | ||||||||
Address2: |   | ||||||||
City: | BARABOO | ||||||||
State: | WI | ||||||||
PostalCode: | 539139064 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083551240 | ||||||||
FaxNumber: | 6083559643 | ||||||||
Practice Location | |||||||||
Address1: | S2845 WHITE EAGLE RD | ||||||||
Address2: |   | ||||||||
City: | BARABOO | ||||||||
State: | WI | ||||||||
PostalCode: | 539139064 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083551240 | ||||||||
FaxNumber: | 6083555166 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2006 | ||||||||
LastUpdateDate: | 02/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2368 | WI | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 0008 | 01 | WI | WPS STATE PART B | OTHER | 38588800WI | 05 | WI |   | MEDICAID |