Provider Demographics
NPI:1447258215
Name:HAGGERTY, JESSE CORNELIUS III (MD, MSC, MPH, PHD)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:CORNELIUS
Last Name:HAGGERTY
Suffix:III
Gender:M
Credentials:MD, MSC, MPH, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 STATE DOCKS RD
Mailing Address - Street 2:
Mailing Address - City:EUFAULA
Mailing Address - State:AL
Mailing Address - Zip Code:36027-3354
Mailing Address - Country:US
Mailing Address - Phone:334-687-0250
Mailing Address - Fax:334-687-0299
Practice Address - Street 1:515 STATE DOCKS RD
Practice Address - Street 2:
Practice Address - City:EUFAULA
Practice Address - State:AL
Practice Address - Zip Code:36027-3354
Practice Address - Country:US
Practice Address - Phone:334-687-0250
Practice Address - Fax:334-687-0299
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049855207Q00000X
AL01D0985382291U00000X
AL24003207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL131642Medicaid
AL51125074OtherBC/BS
GA000910049AMedicaid
ALE48541Medicare UPIN