Provider Demographics
NPI:1699717165
Name:HAAG, JERRY L (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:L
Last Name:HAAG
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 1:350 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:ELMER
Mailing Address - State:NJ
Mailing Address - Zip Code:08318-2143
Mailing Address - Country:US
Mailing Address - Phone:856-358-8113
Mailing Address - Fax:856-358-1305
Practice Address - Street 1:350 FRONT ST
Practice Address - Street 2:
Practice Address - City:ELMER
Practice Address - State:NJ
Practice Address - Zip Code:08318-2143
Practice Address - Country:US
Practice Address - Phone:856-358-8113
Practice Address - Fax:856-358-1305
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02782500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2196409Medicaid
NJ056532Medicare ID - Type Unspecified
NJC52841Medicare UPIN