Provider Demographics
NPI:1639131220
Name:HASKELL, BRENT ALAN (DO)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:ALAN
Last Name:HASKELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1338 PHAY AVE
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-2302
Mailing Address - Country:US
Mailing Address - Phone:719-285-2646
Mailing Address - Fax:719-285-2647
Practice Address - Street 1:1338 PHAY AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2302
Practice Address - Country:US
Practice Address - Phone:719-285-2646
Practice Address - Fax:719-285-2647
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO34749204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO13329OtherCO ANTHEM PIN
CO89F14HAOtherBCBS OF MINN. PIN
COP00027804OtherRAILROAD MEDICARE PIN
CO89F14HAOtherBCBS OF MINN. PIN
COC483678Medicare PIN