Basic Information
| Provider Information | |||||||||
| NPI: | 1619935475 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAGGENJOS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 W WHITE RIVER BLVD | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473034988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776685621 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 428 WEST VOTAW STREET | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PORTLAND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473710710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607268822 | ||||||||
| FaxNumber: | 2607267857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 01/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 02001027A | IN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208M00000X | 02001027A | IN | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 02001027A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100348680 | 05 | IN | MEDICAID |