Provider Demographics
NPI:1710923826
Name:HAGGSTROM, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:HAGGSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4460
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104
Mailing Address - Country:US
Mailing Address - Phone:886-491-5807
Mailing Address - Fax:913-491-0411
Practice Address - Street 1:16901 LAKESIDE HILLS CT
Practice Address - Street 2:ALEGENT LAKESIDE HOSPITAL DEPT OF RADIOLOGY
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2318
Practice Address - Country:US
Practice Address - Phone:402-717-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE205532085R0202X
IA318592085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA6165159Medicaid
NE14706OtherLICENSE #
821OtherMIDLANDS
IA31859OtherLICENSE #
NE35328OtherBCBS
IA2165159Medicaid
IA3165159Medicaid
IA5165159Medicaid
IABH4712851OtherCONTROLLED SUBSTANCE
IA40621OtherBCBS
IA4165159Medicaid
IA4165159Medicaid
IAI3317Medicare PIN
BH5557294OtherDEA #
NE35328OtherBCBS
IA6165159Medicaid
IA4165159Medicaid
NENA1356021Medicare PIN
821OtherMIDLANDS