Provider Demographics
NPI:1659439610
Name:HAAG, ROGER B (OD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:B
Last Name:HAAG
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 1:107 N LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1210
Mailing Address - Country:US
Mailing Address - Phone:248-437-2002
Mailing Address - Fax:248-437-6838
Practice Address - Street 1:107 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-1210
Practice Address - Country:US
Practice Address - Phone:248-437-2002
Practice Address - Fax:248-437-6838
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002500152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0421320001OtherMED-B-DME
MI813459OtherEYEMED VISION CARE
MI1754793Medicaid
MI900F367430OtherBLUE CROSS BLUE SHIELD
MIVC630013OtherM-CARE VISION
MI813459OtherEYEMED VISION CARE
MIVC630013OtherM-CARE VISION