Provider Demographics
NPI:1417174541
Name:HAAG, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HAAG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 N MOUNTAIN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-2572
Mailing Address - Country:US
Mailing Address - Phone:928-759-7072
Mailing Address - Fax:
Practice Address - Street 1:3100 N MOUNTAIN VIEW DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2572
Practice Address - Country:US
Practice Address - Phone:928-759-7072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ839392OtherAHCCCS IDENTIFICATION #