MEDICARE: JOHN C HACKENBERG D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	OS3216	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083603245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN C HACKENBERG D.O.

Provider Business Mailing Address
First Line	:	2675 WINKLER AVE FL 2
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-9342
Country	:	US
Telephone Number	:	877-856-3774
Fax Number	:

Provider Business Practice Location Address
First Line	:	4131 UNIVERSITY BLVD S
Second Line	:	BLDG #8
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-4326
Country	:	US
Telephone Number	:	904-733-3992
Fax Number	:	904-737-4344

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2005
Last Update Date	:	09/29/2021

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