Provider Demographics
NPI:1710092267
Name:HAAS, GWEN H (MD)
Entity Type:Individual
Prefix:DR
First Name:GWEN
Middle Name:H
Last Name:HAAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:H
Other - Last Name:HAAS-HAWKINGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 714328
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271-4328
Mailing Address - Country:US
Mailing Address - Phone:440-833-2095
Mailing Address - Fax:440-833-2096
Practice Address - Street 1:29804 LAKESHORE BLVD
Practice Address - Street 2:
Practice Address - City:WILLOWICK
Practice Address - State:OH
Practice Address - Zip Code:44095
Practice Address - Country:US
Practice Address - Phone:440-833-2095
Practice Address - Fax:440-833-2096
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35058311207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH857390Medicaid
OH857390Medicaid
HA4129081Medicare ID - Type Unspecified