Provider Demographics
NPI:1174311070
Name:HAITSHAN, CARMEN CHRISTINA
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:CHRISTINA
Last Name:HAITSHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:CHRISTINA
Other - Last Name:LOPEZ OLIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2128 B ST NW
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-1865
Mailing Address - Country:US
Mailing Address - Phone:539-577-9175
Mailing Address - Fax:
Practice Address - Street 1:2128 B ST NW
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-1865
Practice Address - Country:US
Practice Address - Phone:539-577-9175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist