Provider Demographics
NPI:1417044355
Name:HAGGERTY, PAUL FLAVIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:FLAVIAN
Last Name:HAGGERTY
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 1:6661 CLYO RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2702
Mailing Address - Country:US
Mailing Address - Phone:937-425-4000
Mailing Address - Fax:937-425-4002
Practice Address - Street 1:6661 CLYO RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-2702
Practice Address - Country:US
Practice Address - Phone:937-425-4000
Practice Address - Fax:937-425-4002
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241946207R00000X
OH35.128129207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0383499Medicaid