Provider Demographics
NPI:1952382095
Name:HAFNER, MARK C (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:HAFNER
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 1:7417 N CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3637
Mailing Address - Country:US
Mailing Address - Phone:559-436-0871
Mailing Address - Fax:559-436-5221
Practice Address - Street 1:1303 E HERNDON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3309
Practice Address - Country:US
Practice Address - Phone:559-450-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG87487207L00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00664238OtherRAILROAD MEDICARE
CACA110535Medicare PIN
CAP00664238OtherRAILROAD MEDICARE
9685672OtherGHI
050027686Medicare ID - Type UnspecifiedRAILROAD MEDICARE
00040449701OtherUNIVERA HEALTHCARE
000410986003OtherBLUE SHIELD NENY
MH000A3210OtherEMPIRE BLUE CROSS
E34073OtherAMERICAN PROGRESSIVE
CAN1750884OtherWORKERS COMP
141540889OtherCIGNA
NY040426006653Medicaid
4151209OtherMOHAWK VALLEY PHYSICIANS
MH09K88310OtherEMPIRE BLUE CROSS
110160500OtherUS DEPT OF LABOR
175088OtherTRICARE
E34073Medicare UPIN
33588BMedicare ID - Type UnspecifiedFIDELIS MEDICARE
33588BMedicare ID - Type Unspecified
NY01166889Medicaid