Provider Demographics
NPI:1992701536
Name:HAKES, DAVID KENNETH (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:KENNETH
Last Name:HAKES
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 1:2019 JEFFERSON RD
Mailing Address - Street 2:STE A
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-3258
Mailing Address - Country:US
Mailing Address - Phone:507-645-9202
Mailing Address - Fax:507-645-9203
Practice Address - Street 1:2019 JEFFERSON RD
Practice Address - Street 2:STE A
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-3258
Practice Address - Country:US
Practice Address - Phone:507-645-9202
Practice Address - Fax:507-645-9203
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLD2735000152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4005210-00Medicaid
MN177K0HAOtherBLUE CROSS BLUE SHIELD MN
MN850754OtherAMERICA'S PPO
MN123686OtherU CARE, MN
MN123686OtherU CARE, MN
MNU78514Medicare UPIN