Healthcare Provider Details

I. General information

NPI: 1447258215
Provider Name (Legal Business Name): JESSE CORNELIUS HAGGERTY III MD, MSC, MPH, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 02/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 STATE DOCKS RD
EUFAULA AL
36027-3354
US

IV. Provider business mailing address

515 STATE DOCKS RD
EUFAULA AL
36027-3354
US

V. Phone/Fax

Practice location:
  • Phone: 334-687-0250
  • Fax: 334-687-0299
Mailing address:
  • Phone: 334-687-0250
  • Fax: 334-687-0299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number049855
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number01D0985382
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24003
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: