Provider Demographics
NPI:1508834466
Name:HAUGLAND, GORDON (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:
Last Name:HAUGLAND
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 1:2323 W ROSE GARDEN LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-2530
Mailing Address - Country:US
Mailing Address - Phone:602-521-6200
Mailing Address - Fax:623-842-5640
Practice Address - Street 1:5605 W EUGIE AVE STE 110
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1273
Practice Address - Country:US
Practice Address - Phone:623-847-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ332552085R0204X, 2085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ886616Medicaid
AZAZ0765710OtherBCBSAZ
AZ1Z7135OtherHEALTH NET OF AZ
AZP00150753Medicare PIN
AZAZ0765710OtherBCBSAZ
AZ886616Medicaid
Z182949Medicare PIN