Provider Demographics
NPI:1760660765
Name:HAASTRUP, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HAASTRUP
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 1:912 N KENTUCKY AVE # A16
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-1663
Mailing Address - Country:US
Mailing Address - Phone:270-825-0813
Mailing Address - Fax:
Practice Address - Street 1:912 N KENTUCKY AVE # A16
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1663
Practice Address - Country:US
Practice Address - Phone:270-825-0813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-01
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301091214207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine