Provider Demographics
NPI:1629019682
Name:HAAK, ROBERT GUSTAV (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GUSTAV
Last Name:HAAK
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 1:32 CLOVER LN
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-2867
Mailing Address - Country:US
Mailing Address - Phone:610-688-3433
Mailing Address - Fax:610-688-2456
Practice Address - Street 1:900 W VALLEY RD STE 601
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-1825
Practice Address - Country:US
Practice Address - Phone:610-688-3433
Practice Address - Fax:610-688-2456
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000298152W00000X
NJ27OA00563700152W00000X
DEI3-0001257152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01757365Medicaid
PA01757365Medicaid
PA028549Medicare PIN