Provider Demographics
NPI:1659320752
Name:HAESEKER, JOHN CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
Last Name:HAESEKER
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 1:11550 MERIDIAN MARKET VIEW
Mailing Address - Street 2:WALMART VISION CENTER #4335
Mailing Address - City:PEYTON
Mailing Address - State:CO
Mailing Address - Zip Code:80831-8233
Mailing Address - Country:US
Mailing Address - Phone:719-495-5055
Mailing Address - Fax:719-495-0574
Practice Address - Street 1:11550 MERIDIAN MARKET VIEW
Practice Address - Street 2:WALMART VISION CENTER #4335
Practice Address - City:PEYTON
Practice Address - State:CO
Practice Address - Zip Code:80831-8233
Practice Address - Country:US
Practice Address - Phone:719-495-5055
Practice Address - Fax:719-495-0574
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1476152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO13227271Medicaid
C482908OtherMEDICARE GROUP
CO85628379OtherMEDICAID PIN
CO85628379OtherMEDICAID PIN
U18635Medicare UPIN