Provider Demographics
NPI:1992808794
Name:HAGGERTY, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HAGGERTY
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 1:5533 MAHONING AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-2366
Mailing Address - Country:US
Mailing Address - Phone:330-793-7966
Mailing Address - Fax:330-793-8688
Practice Address - Street 1:5533 MAHONING AVE
Practice Address - Street 2:SUITE D
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-2366
Practice Address - Country:US
Practice Address - Phone:330-793-7966
Practice Address - Fax:330-793-8688
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070508207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0258984Medicaid
OHG28293Medicare UPIN
OH0258984Medicaid