Provider Demographics
NPI:1508863978
Name:HAGGARD, JOE REX (OD)
Entity Type:Individual
Prefix:DR
First Name:JOE
Middle Name:REX
Last Name:HAGGARD
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 1:1055 N 300 W
Mailing Address - Street 2:STE 204
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3374
Mailing Address - Country:US
Mailing Address - Phone:801-357-7373
Mailing Address - Fax:801-357-7217
Practice Address - Street 1:1055 N 300 W
Practice Address - Street 2:STE 204
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3374
Practice Address - Country:US
Practice Address - Phone:801-357-7373
Practice Address - Fax:801-357-7217
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1131489934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD0696Medicaid
UTU53033Medicare UPIN
UT000060563Medicare PIN