Provider Demographics
NPI:1447356860
Name:HAIDERER, DONALD E (OD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:E
Last Name:HAIDERER
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 1:5416 MICHAEL RD
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-3004
Mailing Address - Country:US
Mailing Address - Phone:989-684-9203
Mailing Address - Fax:
Practice Address - Street 1:5416 MICHAEL RD
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-3004
Practice Address - Country:US
Practice Address - Phone:989-684-9203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003099152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4861797Medicaid
MIM88090016Medicare ID - Type Unspecified
MIP00268080Medicare ID - Type UnspecifiedRAILROAD
MIM89690017Medicare ID - Type Unspecified
MI4861797Medicaid