MEDICARE: DR. EDWARD HAACK O.D.

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	152W00000X	Optometrist	10326T	CA

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	:	1174516462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWARD HAACK O.D.

Provider Business Mailing Address
First Line	:	1102 MAGNOLIA AVE
Second Line	:
City	:	LARKSPUR
State	:	CA
Zip	:	94939-1054
Country	:	US
Telephone Number	:	415-891-9090
Fax Number	:	415-891-9080

Provider Business Practice Location Address
First Line	:	1102 MAGNOLIA AVE
Second Line	:
City	:	LARKSPUR
State	:	CA
Zip	:	94939-1054
Country	:	US
Telephone Number	:	415-891-9090
Fax Number	:	415-891-9080

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

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	03/28/2017

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