=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558448118
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN WALTER HASKEW MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 02/20/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1351 COLLYER ST
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80501-3310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-776-7117
-----------------------------------------------------
Fax | 888-863-4354
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 312 1351 COLLYER
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80502-0312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-776-7117
-----------------------------------------------------
Fax | 888-863-4354
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 18992
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 18992
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------