Provider Demographics
NPI:1174857940
Name:HAYNES, ANDRE VONTRAL (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:VONTRAL
Last Name:HAYNES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 RUGGED CREEK DR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:229 RUGGED CREEK DR
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-4568
Practice Address - Country:US
Practice Address - Phone:404-783-0792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.29119208D00000X
GA68818208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice