Provider Demographics
NPI:1235395849
Name:HAYWARD, DUSTIN MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:MARK
Last Name:HAYWARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:12039 NE 128TH ST STE 500
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034
Practice Address - Country:US
Practice Address - Phone:425-899-5590
Practice Address - Fax:425-899-5588
Is Sole Proprietor?:No
Enumeration Date:2008-08-03
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125055496207T00000X
WAMD60546371207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8957538Medicare UPIN