Provider Demographics
NPI:1124561113
Name:DUSTIN O. HAYES, D.O., P.C.
Entity Type:Organization
Organization Name:DUSTIN O. HAYES, D.O., P.C.
Other - Org Name:ECLIPSE MENTAL HEALTH SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:O'LEATH
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-940-4734
Mailing Address - Street 1:817 S ELM PL
Mailing Address - Street 2:SUITE C
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5369
Mailing Address - Country:US
Mailing Address - Phone:918-940-4734
Mailing Address - Fax:918-940-4737
Practice Address - Street 1:817 S ELM PL
Practice Address - Street 2:SUITE C
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-5369
Practice Address - Country:US
Practice Address - Phone:918-940-4734
Practice Address - Fax:918-940-4737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-23
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5382208D00000X
261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200678490AMedicaid