Provider Demographics
NPI:1134103856
Name:HACKERT, JOHN BRADLEY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BRADLEY
Last Name:HACKERT
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 1:4413 SOPHISTRY DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95742-8073
Mailing Address - Country:US
Mailing Address - Phone:916-202-4297
Mailing Address - Fax:
Practice Address - Street 1:4413 SOPHISTRY DR
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95742-8073
Practice Address - Country:US
Practice Address - Phone:916-202-4297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82374208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
I07788Medicare UPIN