Healthcare Provider Details

I. General information

NPI: 1417044355
Provider Name (Legal Business Name): PAUL FLAVIAN HAGGERTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6661 CLYO RD
CENTERVILLE OH
45459-2702
US

IV. Provider business mailing address

6661 CLYO RD
CENTERVILLE OH
45459-2702
US

V. Phone/Fax

Practice location:
  • Phone: 937-425-4000
  • Fax: 937-425-4002
Mailing address:
  • Phone: 937-425-4000
  • Fax: 937-425-4002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101241946
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.128129
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: