Provider Demographics
NPI:1326046616
Name:HAYGOOD, KENNETH DONALD (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DONALD
Last Name:HAYGOOD
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 1:1304 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2262
Mailing Address - Country:US
Mailing Address - Phone:903-531-2320
Mailing Address - Fax:
Practice Address - Street 1:1304 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2262
Practice Address - Country:US
Practice Address - Phone:903-531-2320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2341207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01200574OtherRAIL ROAD
TX8DQ314OtherBCBS
TX046531205Medicaid
TX046531203Medicaid
TX752616977042OtherTRICARE
TX752616977042OtherTRICARE
G89791Medicare UPIN
8770B0Medicare ID - Type Unspecified