Healthcare Provider Details

I. General information

NPI: 1508211947
Provider Name (Legal Business Name): DAMIAN CHARLES HANEKOM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2441 SURFSIDE BLVD STE 200
CAPE CORAL FL
33914-3861
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-424-1499
  • Fax:
Mailing address:
  • Phone: 239-541-7500
  • Fax: 239-541-7501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME139796
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.068045
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: