Provider Demographics
NPI:1376522029
Name:HAFNER, JASON M (OD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:HAFNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 STEAMBOAT CIR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-4878
Mailing Address - Country:US
Mailing Address - Phone:605-720-5174
Mailing Address - Fax:
Practice Address - Street 1:910 HARMON ST
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:SD
Practice Address - Zip Code:57785-2556
Practice Address - Country:US
Practice Address - Phone:605-347-2666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD590152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9201360Medicaid
SDU92594Medicare UPIN
SD9201360Medicaid