Healthcare Provider Details

I. General information

NPI: 1992701536
Provider Name (Legal Business Name): DAVID KENNETH HAKES O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 05/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 JEFFERSON RD STE A
NORTHFIELD MN
55057-3258
US

IV. Provider business mailing address

2019 JEFFERSON RD STE A
NORTHFIELD MN
55057-3258
US

V. Phone/Fax

Practice location:
  • Phone: 507-645-9202
  • Fax: 507-645-9203
Mailing address:
  • Phone: 507-645-9202
  • Fax: 507-645-9203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberLD2735000
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberLD2735000
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberLD2735000
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: