Provider Demographics
NPI:1750325544
Name:HAEGELE, MARK (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HAEGELE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4512 KIRKWOOD HWY STE 202
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-5122
Mailing Address - Country:US
Mailing Address - Phone:302-999-0137
Mailing Address - Fax:302-999-1042
Practice Address - Street 1:4512 KIRKWOOD HWY STE 202
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-5122
Practice Address - Country:US
Practice Address - Phone:302-999-0137
Practice Address - Fax:302-999-1042
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2014-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0003560207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000912203Medicaid
DE0000912203Medicaid
E89131Medicare UPIN