Provider Demographics
NPI:1285667782
Name:HAEUFGLOECKNER, ANTHONY (DO)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:HAEUFGLOECKNER
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 1:4320 CLEVELAND AVE SE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44707-1143
Mailing Address - Country:US
Mailing Address - Phone:330-484-2584
Mailing Address - Fax:330-484-3529
Practice Address - Street 1:4320 CLEVELAND AVE SE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44707-1143
Practice Address - Country:US
Practice Address - Phone:330-484-2584
Practice Address - Fax:330-484-3529
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008117207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2566567Medicaid
OH34008117OtherLICENSE
OH4160112Medicare PIN
OH2566567Medicaid
OHI31235Medicare UPIN