Provider Demographics
NPI:1023198959
Name:HAFERKAMP, SHAWN M (OD)
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:M
Last Name:HAFERKAMP
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 DOVE CT
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-7709
Mailing Address - Country:US
Mailing Address - Phone:573-783-3573
Mailing Address - Fax:573-783-5946
Practice Address - Street 1:152 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-1452
Practice Address - Country:US
Practice Address - Phone:573-783-3573
Practice Address - Fax:573-783-5946
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004016911152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOV01973Medicare UPIN