Provider Demographics
NPI:1275635427
Name:HAITHCOCK, DANIEL B (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:B
Last Name:HAITHCOCK
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 1:639 HEMLOCK ST.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-6889
Mailing Address - Country:US
Mailing Address - Phone:478-755-1560
Mailing Address - Fax:478-755-1562
Practice Address - Street 1:242 KING AVENUE SUITE 210
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606
Practice Address - Country:US
Practice Address - Phone:706-475-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400346207RC0000X
GA061887207RC0000X
ZZ061887207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA931451901AMedicaid
BH8048236OtherDEA
GA931451901AMedicaid