Provider Demographics
NPI:1225023070
Name:ADAGIO DERMATOLOGY AND AESTHETICS, P.A.
Entity Type:Organization
Organization Name:ADAGIO DERMATOLOGY AND AESTHETICS, P.A.
Other - Org Name:LAURA J. HAYGOOD, M.D., P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:JENNIFER
Authorized Official - Last Name:HAYGOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-597-3376
Mailing Address - Street 1:455 RICE ROAD
Mailing Address - Street 2:STE. 104
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3604
Mailing Address - Country:US
Mailing Address - Phone:903-597-3376
Mailing Address - Fax:903-526-7703
Practice Address - Street 1:455 RICE ROAD
Practice Address - Street 2:STE. 104
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3604
Practice Address - Country:US
Practice Address - Phone:903-597-3376
Practice Address - Fax:903-526-7703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3905174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0082DNOtherBLUE CROSS BLUE SHIELD
TX8C9410Medicare PIN
TX00745XMedicare PIN
TXG95735Medicare UPIN