Provider Demographics
NPI:1316070113
Name:HAFFNER, GEORGE LESLIE (OD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:LESLIE
Last Name:HAFFNER
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 1:408 LAKEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-1829
Mailing Address - Country:US
Mailing Address - Phone:813-994-4800
Mailing Address - Fax:813-994-9940
Practice Address - Street 1:19412 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3062
Practice Address - Country:US
Practice Address - Phone:813-994-4800
Practice Address - Fax:813-994-9940
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC656152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101201OtherEYEMED
FL19838Medicare ID - Type UnspecifiedPROVIDER NUMBER
FL101201OtherEYEMED