Basic Information
Provider Information | |||||||||
NPI: | 1841383197 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAAG | ||||||||
FirstName: | TERRY | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 83 W MILLER ST | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328062028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3218415281 | ||||||||
FaxNumber: | 4076489879 | ||||||||
Practice Location | |||||||||
Address1: | 83 W MILLER ST | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328062028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3218415281 | ||||||||
FaxNumber: | 4076489879 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/01/2006 | ||||||||
LastUpdateDate: | 11/16/2016 | ||||||||
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 | 207V00000X | OS10169 | FL | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207V00000X | 9185491-1204 | UT | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 036113969 | 05 | IL |   | MEDICAID | 280166300 | 05 | FL |   | MEDICAID | 09806 | 01 | FL | BCBS OF FLORIDA | OTHER | OS10169 | 01 | FL | MEDICAL LICENSE | OTHER |