Provider Demographics
NPI:1407899909
Name:HAAK, RICHARD BRAINARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:BRAINARD
Last Name:HAAK
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 1:101 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0556
Mailing Address - Country:US
Mailing Address - Phone:209-571-6622
Mailing Address - Fax:209-527-2069
Practice Address - Street 1:1524 MCHENRY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4500
Practice Address - Country:US
Practice Address - Phone:209-577-4444
Practice Address - Fax:209-527-2069
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA630262085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A630260Medicaid
CA00A6302610Medicare PIN
CA00A630263Medicare PIN
CAH14813Medicare UPIN
CA00A630265Medicare PIN
CA00A630267Medicare PIN
CA00A630261Medicare PIN
CA00A630269Medicare PIN
CA00A6302612Medicare PIN
CA00A6302613Medicare PIN
CA00A630260Medicare PIN
CA00A630262Medicare PIN
CA300134256Medicare PIN
CA00A630260Medicaid
CA00A6302614Medicare PIN
CA00A630264Medicare PIN
CA00A630266Medicare PIN
CA00A630268Medicare PIN