Provider Demographics
NPI:1952300923
Name:HAGGERTY, CLEMENS E (DO)
Entity Type:Individual
Prefix:DR
First Name:CLEMENS
Middle Name:E
Last Name:HAGGERTY
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:PO BOX 1500
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-1500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2333 HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:IBERIA
Practice Address - State:MO
Practice Address - Zip Code:65486-9331
Practice Address - Country:US
Practice Address - Phone:573-793-6900
Practice Address - Fax:573-793-6688
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO30307208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO240891200Medicaid
MO010052082OtherRAILROAD MEDICARE
MO240891200Medicaid
MO012013557Medicare PIN