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General NPI Number Information
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NPI Number | 1619935475
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Entity Type | Individual
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Provider Name | MARK ALLEN HAGGENJOS D.O.
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Gender | Male
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Dates
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Enumeration Date | 05/02/2006
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Last Update Date | 01/08/2021
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Provider Practice Location Address
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Address Line | 428 WEST VOTAW STREET SUITE A
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City | PORTLAND
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State | IN
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Zip | 47371-0710
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Country | US
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Telephone | 260-726-8822
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Fax | 260-726-7857
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Provider Business Mailing Address
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Address Line | 1200 W WHITE RIVER BLVD
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City | MUNCIE
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State | IN
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Zip | 47303-4988
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Country | US
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Telephone | 877-668-5621
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 02001027A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 208M00000X
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Taxonomy Name | Hospitalist Physician
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License Number | 02001027A
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 02001027A
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License Number State | IN
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