Provider Demographics
NPI:1184660565
Name:HAINES, PHILIP OLIVER (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:OLIVER
Last Name:HAINES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:916-379-2871
Mailing Address - Fax:916-853-4730
Practice Address - Street 1:6305 COYLE AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0438
Practice Address - Country:US
Practice Address - Phone:916-961-6920
Practice Address - Fax:916-966-5063
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG243562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G243560OtherMEDI-CAL
P00204007OtherRAILROAD MEDICARE
CA680220314OtherFEDERAL TIN
CA00G243560OtherMEDI-CAL