Basic Information
| Provider Information | |||||||||
| NPI: | 1932180312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAEDT | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | PERRY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 303 3RD ST NE | ||||||||
| Address2: | |||||||||
| City: | MADELIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560621715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734331204 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1850 ADAMS ST STE 112 | ||||||||
| Address2: | |||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560014846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073876358 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 01/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2994 | MN | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.