Provider Demographics
NPI:1235152323
Name:HAFER, GARY A (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:A
Last Name:HAFER
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 1:529 WEST 200 NORTH
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:UT
Mailing Address - Zip Code:84049
Mailing Address - Country:US
Mailing Address - Phone:435-487-1112
Mailing Address - Fax:
Practice Address - Street 1:529 WEST 200 NORTH
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:UT
Practice Address - Zip Code:84049
Practice Address - Country:US
Practice Address - Phone:435-487-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG035674174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA91708Medicare UPIN