Provider Demographics
NPI:1699977686
Name:HABERMAN, BRENT K (MD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:K
Last Name:HABERMAN
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 1:1465 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1003
Mailing Address - Country:US
Mailing Address - Phone:314-268-6439
Mailing Address - Fax:314-268-6412
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-268-6413
Practice Address - Fax:314-268-6412
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-03
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016042899208000000X, 2080P0214X, 2080S0012X
TN475262080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology