Provider Demographics
NPI:1326373606
Name:BRENT HAYDEN, M.D.,P.A.
Entity Type:Organization
Organization Name:BRENT HAYDEN, M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:HAYDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-755-0645
Mailing Address - Street 1:733 SW STATE ROAD 47
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-0453
Mailing Address - Country:US
Mailing Address - Phone:386-755-0645
Mailing Address - Fax:386-961-9541
Practice Address - Street 1:733 SW STATE ROAD 47
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0453
Practice Address - Country:US
Practice Address - Phone:386-755-0645
Practice Address - Fax:386-961-9541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0043394OtherSTATE LICENCE NUMBER
FL12066OtherMEDICARE ID-TYPE UNSPECIFIED
FL041891900Medicaid
FLE34632Medicare UPIN