Provider Demographics
NPI:1386739548
Name:HAAKE, RONALD E (DO)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:E
Last Name:HAAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S. NEW BALLAS ROAD
Mailing Address - Street 2:SUITE 4006-B
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-251-6486
Mailing Address - Fax:314-251-4155
Practice Address - Street 1:621 S. NEW BALLAS ROAD
Practice Address - Street 2:SUITE 4006-B
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-251-6486
Practice Address - Fax:314-251-4155
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006016773207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00398710OtherRAILROAD MEDICARE
MO1386739548Medicaid
MO1386739548Medicaid