Provider Demographics
NPI:1790703288
Name:HACKLEY, DAVID R (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:HACKLEY
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 1:9850 GENESEE AVE.
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1244
Mailing Address - Country:US
Mailing Address - Phone:858-535-1075
Mailing Address - Fax:858-453-9810
Practice Address - Street 1:9850 GENESEE AVE.
Practice Address - Street 2:SUITE 210
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1244
Practice Address - Country:US
Practice Address - Phone:858-535-1075
Practice Address - Fax:858-453-9810
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75801207X00000X, 207XX0005X, 207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
W15730AMedicare ID - Type Unspecified
G43363Medicare UPIN
CAG43363Medicare UPIN
W15730Medicare ID - Type Unspecified