Provider Demographics
NPI:1740206119
Name:HAAKE, BRANDON (MD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:HAAKE
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 1650
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44309-1650
Mailing Address - Country:US
Mailing Address - Phone:330-864-8900
Mailing Address - Fax:330-869-8924
Practice Address - Street 1:217 S 3RD ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1823
Practice Address - Country:US
Practice Address - Phone:859-335-9041
Practice Address - Fax:859-335-9072
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38865207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2496553Medicaid
KY50005459OtherPASSPORT
KY64080898Medicaid
KY000000330903OtherANTHEM
WV3000721OtherBWC
WV3810004518Medicaid
WV3000721OtherBWC
KY0693563Medicare ID - Type Unspecified