Healthcare Provider Details

I. General information

NPI: 1487177721
Provider Name (Legal Business Name): JEREMY HAUPTMAN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9069 W THUNDERBIRD RD
PEORIA AZ
85381-4412
US

IV. Provider business mailing address

25500 N NORTERRA DR
PHOENIX AZ
85085-8200
US

V. Phone/Fax

Practice location:
  • Phone: 623-977-7201
  • Fax: 623-876-2129
Mailing address:
  • Phone: 623-277-1130
  • Fax: 866-837-6575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2932
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2198
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: