Healthcare Provider Details

I. General information

NPI: 1659524643
Provider Name (Legal Business Name): ERIC C HAAG DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2008
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4707 RIO ST
FARMINGTON NM
87402-5323
US

IV. Provider business mailing address

4707 RIO ST
FARMINGTON NM
87402-5323
US

V. Phone/Fax

Practice location:
  • Phone: 505-787-9035
  • Fax:
Mailing address:
  • Phone: 505-787-9035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberPOD332
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPOD332
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number332
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: