MEDICARE: DR. DAVID KENNETH HAKES 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	LD2735000	MN
2	152WC0802X	Corneal and Contact Management Optometrist	LD2735000	MN
3	152WP0200X	Pediatric Optometrist	LD2735000	MN

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
2	177K0HA	OTHER	MN	BLUE CROSS BLUE SHIELD MN
3	850754	OTHER	MN	AMERICA'S PPO
4	123686	OTHER	MN	U CARE, MN

General Provider Information

NPI Number	:	1992701536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID KENNETH HAKES O.D.

Provider Business Mailing Address
First Line	:	2019 JEFFERSON RD
Second Line	:	STE A
City	:	NORTHFIELD
State	:	MN
Zip	:	55057-3258
Country	:	US
Telephone Number	:	507-645-9202
Fax Number	:	507-645-9203

Provider Business Practice Location Address
First Line	:	2019 JEFFERSON RD
Second Line	:	STE A
City	:	NORTHFIELD
State	:	MN
Zip	:	55057-3258
Country	:	US
Telephone Number	:	507-645-9202
Fax Number	:	507-645-9203

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

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	05/05/2011

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