Provider Demographics
NPI:1942245113
Name:HAKANSSON, MIKAEL K (MD)
Entity Type:Individual
Prefix:
First Name:MIKAEL
Middle Name:K
Last Name:HAKANSSON
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 1:533 SESPE AVE
Mailing Address - Street 2:STE #C
Mailing Address - City:FILLMORE
Mailing Address - State:CA
Mailing Address - Zip Code:93015-1985
Mailing Address - Country:US
Mailing Address - Phone:805-524-2749
Mailing Address - Fax:805-524-6929
Practice Address - Street 1:533 SESPE AVE
Practice Address - Street 2:STE #C
Practice Address - City:FILLMORE
Practice Address - State:CA
Practice Address - Zip Code:93015-1985
Practice Address - Country:US
Practice Address - Phone:805-524-2749
Practice Address - Fax:805-524-6929
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88831207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM08608FMedicaid
CA050394OtherBLUE CROSS
CA95-1683892OtherOTHER INSURANCE
CARHM18553HMedicaid
CAZZT40394FMedicaid
CA00A888310Medicaid
CARHM08609FMedicaid
CA050394Medicare ID - Type UnspecifiedMEDICARE
CA058608Medicare ID - Type UnspecifiedRH MEDICARE
CAWA88831DMedicare ID - Type UnspecifiedPPIN
CARHM18553HMedicaid
CARHM08608FMedicaid
I33487Medicare UPIN
CAWA88831GMedicare ID - Type UnspecifiedPPIN
CAWA88831EMedicare ID - Type UnspecifiedPPIN
CA00A888310Medicaid
CAWA88831HMedicare ID - Type UnspecifiedPPIN
CA050394OtherBLUE CROSS
CARHM08609FMedicaid