Provider Demographics
NPI:1407859440
Name:HAYNES, MICHAEL J (O D)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:HAYNES
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 FORSYTHE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3008
Mailing Address - Country:US
Mailing Address - Phone:318-323-4994
Mailing Address - Fax:318-388-6913
Practice Address - Street 1:2808 FORSYTHE AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3008
Practice Address - Country:US
Practice Address - Phone:318-323-4994
Practice Address - Fax:318-388-6913
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA891-26T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1326879Medicaid
LA1326879Medicaid
LA5DJ33Medicare PIN