Provider Demographics
NPI:1790718682
Name:HABERMAN, PHILLIP J (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:J
Last Name:HABERMAN
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 1:5802 WRIGHT DR
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-8806
Mailing Address - Country:US
Mailing Address - Phone:970-212-0530
Mailing Address - Fax:
Practice Address - Street 1:5802 WRIGHT DR
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-8806
Practice Address - Country:US
Practice Address - Phone:970-212-0530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0054737207ZC0500X, 207ZP0102X
WY6366A207ZP0102X
NE17949207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F09786Medicare UPIN