Provider Demographics
NPI:1083603245
Name:HACKENBERG, JOHN C (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:HACKENBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:4131 UNIVERSITY BLVD S
Practice Address - Street 2:BLDG #8
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4326
Practice Address - Country:US
Practice Address - Phone:904-733-3992
Practice Address - Fax:904-737-4344
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS3216207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
81800Medicare ID - Type Unspecified
FLD27330Medicare UPIN