Provider Demographics
NPI:1487177721
Name:HAUPTMAN, JEREMY (OD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:HAUPTMAN
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 1:25500 N NORTERRA DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-8200
Mailing Address - Country:US
Mailing Address - Phone:623-277-1130
Mailing Address - Fax:866-837-6575
Practice Address - Street 1:9069 W THUNDERBIRD RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4412
Practice Address - Country:US
Practice Address - Phone:623-977-7201
Practice Address - Fax:623-876-2129
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2932152W00000X
AZ2198152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ396097Medicaid