Provider Demographics
NPI:1235114729
Name:HAVERTY, MICHAEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:HAVERTY
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 1:2342 PROFESSIONAL PKWY
Mailing Address - Street 2:SUITE 260
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-1629
Mailing Address - Country:US
Mailing Address - Phone:805-348-3910
Mailing Address - Fax:805-348-3901
Practice Address - Street 1:2342 PROFESSIONAL PKWY
Practice Address - Street 2:SUITE 260
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-1629
Practice Address - Country:US
Practice Address - Phone:805-348-3910
Practice Address - Fax:805-348-3901
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53646207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG53646OtherBLUE CROSS
CA00G536460OtherBLUE SHIELD PIN
CAA93243Medicare UPIN
WG53646BMedicare PIN
CA00G536460OtherBLUE SHIELD PIN