Provider Demographics
NPI:1558821413
Name:HAERTLING, DOMINIC JEFFREY (MD)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:JEFFREY
Last Name:HAERTLING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 HOSPITAL LN STE 202
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63775-4204
Mailing Address - Country:US
Mailing Address - Phone:573-768-3449
Mailing Address - Fax:573-519-5330
Practice Address - Street 1:212 HOSPITAL LN STE 202
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775-4204
Practice Address - Country:US
Practice Address - Phone:573-768-3449
Practice Address - Fax:573-519-5330
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023016854208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics