Healthcare Provider Details

I. General information

NPI: 1023198959
Provider Name (Legal Business Name): SHAWN M HAFERKAMP OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 S MAIN ST
FREDERICKTOWN MO
63645-1452
US

IV. Provider business mailing address

51 DOVE CT
FARMINGTON MO
63640-7709
US

V. Phone/Fax

Practice location:
  • Phone: 573-783-3573
  • Fax: 573-783-5946
Mailing address:
  • Phone: 573-783-3573
  • Fax: 573-783-5946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2004016911
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: