1992750111 NPI number — DR. SUSAN HAESAERT OD

Table of content: DR. SUSAN HAESAERT OD (NPI 1992750111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992750111 NPI number — DR. SUSAN HAESAERT OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAESAERT
Provider First Name:
SUSAN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992750111
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
BOSTON VA HEALTHCARE SYSTEM
Provider Second Line Business Mailing Address:
150 SOUTH HUNTINGTON AVENUE
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-232-9500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 S HUNTINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02130-4817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-232-9500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2415 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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