Basic Information
| Provider Information | |||||||||
| NPI: | 1215065032 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAAG | ||||||||
| FirstName: | DEANNE | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DIXON | ||||||||
| OtherFirstName: | DEANNE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 66 KNIGHT LN STE 10 | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054959308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028724329 | ||||||||
| FaxNumber: | 8022881144 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 CREST RD | ||||||||
| Address2: | |||||||||
| City: | SAINT ALBANS | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054789701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8025278189 | ||||||||
| FaxNumber: | 8025278187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 042-0010358 | VT | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080A0000X | 0420010358 | VT | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 58746 | 01 | VT | BLUE CROSS BLUE SHIELD | OTHER | 1008802 | 05 | VT | MEDICAID |