Provider Demographics
NPI:1326040361
Name:HAEKER, PENELOPE ANN (OD)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:ANN
Last Name:HAEKER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 SERGEANT RD
Mailing Address - Street 2:SUITE 45
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51106-4775
Mailing Address - Country:US
Mailing Address - Phone:712-224-4600
Mailing Address - Fax:712-276-3716
Practice Address - Street 1:5001 SERGEANT RD
Practice Address - Street 2:SUITE 45
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4775
Practice Address - Country:US
Practice Address - Phone:712-224-4600
Practice Address - Fax:712-276-3716
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02247152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA18018OtherWELLMARCK BCBS
U51094Medicare UPIN
IAI10447Medicare ID - Type Unspecified