Healthcare Provider Details

I. General information

NPI: 1386739548
Provider Name (Legal Business Name): RONALD E. HAAKE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 01/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S. NEW BALLAS ROAD SUITE 4006-B
ST. LOUIS MO
63141
US

IV. Provider business mailing address

621 S. NEW BALLAS ROAD SUITE 4006-B
ST. LOUIS MO
63141
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6486
  • Fax: 314-251-4155
Mailing address:
  • Phone: 314-251-6486
  • Fax: 314-251-4155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number2006016773
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: