Healthcare Provider Details

I. General information

NPI: 1710092267
Provider Name (Legal Business Name): GWEN H HAAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GWEN H. HAAS-HAWKINGS

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29804 LAKESHORE BLVD
WILLOWICK OH
44095
US

IV. Provider business mailing address

PO BOX 714328
COLUMBUS OH
43271-4328
US

V. Phone/Fax

Practice location:
  • Phone: 440-833-2095
  • Fax: 440-833-2096
Mailing address:
  • Phone: 440-833-2095
  • Fax: 440-833-2096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35058311
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: