Provider Demographics
NPI:1386667632
Name:HAGGARD, DERICK RAY (MD)
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:RAY
Last Name:HAGGARD
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 1:3509 22ND STREET
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1307
Mailing Address - Country:US
Mailing Address - Phone:806-799-7928
Mailing Address - Fax:806-788-8560
Practice Address - Street 1:3611 22ND PL
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1317
Practice Address - Country:US
Practice Address - Phone:806-771-2222
Practice Address - Fax:806-771-2224
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8563208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX125719805Medicaid
TXJ8563OtherLICENSE
TXJ8563OtherLICENSE
TX8964K3Medicare ID - Type Unspecified