Provider Demographics
NPI:1295747046
Name:HAAKE, ROBERT JOHN (DO)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOHN
Last Name:HAAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:500 E SHORE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6908
Mailing Address - Country:US
Mailing Address - Phone:208-995-2802
Mailing Address - Fax:208-995-2804
Practice Address - Street 1:500 E SHORE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6908
Practice Address - Country:US
Practice Address - Phone:208-995-2802
Practice Address - Fax:208-995-2804
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2013-07-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDO-0520207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00155781OtherRAILROAD MEDICARE
210613Medicare PIN
ILA13805Medicare UPIN