Basic Information
Provider Information | |||||||||
NPI: | 1629070875 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAGGERTY | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 510 ROUTE 6 AND 209 | ||||||||
Address2: | STE 6 | ||||||||
City: | MILFORD | ||||||||
State: | PA | ||||||||
PostalCode: | 183377615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5702969696 | ||||||||
FaxNumber: | 5704090316 | ||||||||
Practice Location | |||||||||
Address1: | 510 ROUTE 6 AND 209 | ||||||||
Address2: | STE 6 | ||||||||
City: | MILFORD | ||||||||
State: | PA | ||||||||
PostalCode: | 183377615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5702969696 | ||||||||
FaxNumber: | 5704090316 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2005 | ||||||||
LastUpdateDate: | 04/26/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OEG001036 | PA | Y |   | Eye and Vision Services Providers | Optometrist |   |
No ID Information.