Provider Demographics
NPI:1346254331
Name:HABERSANG, ROLF (MD)
Entity Type:Individual
Prefix:
First Name:ROLF
Middle Name:
Last Name:HABERSANG
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 1:1400 WALLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1708
Mailing Address - Country:US
Mailing Address - Phone:806-414-9800
Mailing Address - Fax:806-354-5689
Practice Address - Street 1:1400 S COULTER ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1786
Practice Address - Country:US
Practice Address - Phone:806-414-9800
Practice Address - Fax:806-354-5689
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3484208000000X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137261713Medicaid
TX137261711Medicaid
TX137261712Medicaid
NMX7953Medicaid
OK100084610AMedicaid
TX137161710Medicaid
TX329482YPT8Medicare PIN
TX137161710Medicaid
TX137261712Medicaid