Provider Demographics
NPI:1538367123
Name:HAGGERTY, MICHAEL D JR (IDC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:HAGGERTY
Suffix:JR
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 BAYOU PL
Mailing Address - Street 2:
Mailing Address - City:DIAMONDHEAD
Mailing Address - State:MS
Mailing Address - Zip Code:39525-4108
Mailing Address - Country:US
Mailing Address - Phone:228-871-2810
Mailing Address - Fax:228-871-3725
Practice Address - Street 1:1049 BAYOU PL
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-4108
Practice Address - Country:US
Practice Address - Phone:228-871-2810
Practice Address - Fax:228-871-3725
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman