Provider Demographics
NPI:1215926647
Name:HASKETT, MICHAEL KENT (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KENT
Last Name:HASKETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2047 HAMILTON BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-2141
Mailing Address - Country:US
Mailing Address - Phone:434-572-9733
Mailing Address - Fax:434-572-9736
Practice Address - Street 1:2047 HAMILTON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-2141
Practice Address - Country:US
Practice Address - Phone:434-572-9733
Practice Address - Fax:434-572-9736
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000062152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA063596OtherBLUE CROSS BLUE SHIELD
VA410038621OtherRAILROAD MEDICARE
VA0180770001OtherCIGNA HEALTHCARE DMERC
VA009206019Medicaid
VA009206019Medicaid
VA009206019Medicaid