Healthcare Provider Details

I. General information

NPI: 1619045523
Provider Name (Legal Business Name): THOMAS MARK HABERMAN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4524 N FRITILLARY CT
BEL AIRE KS
67226-4204
US

IV. Provider business mailing address

4524 N FRITILLARY CT
BEL AIRE KS
67226-4204
US

V. Phone/Fax

Practice location:
  • Phone: 316-577-5038
  • Fax: 316-744-6404
Mailing address:
  • Phone: 316-577-5038
  • Fax: 316-744-6404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number12-00296
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: