Provider Demographics
NPI:1497751994
Name:HAITHCOCK, ROBYN LEITH SR (DO)
Entity Type:Individual
Prefix:
First Name:ROBYN
Middle Name:LEITH
Last Name:HAITHCOCK
Suffix:SR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-851-1000
Mailing Address - Fax:
Practice Address - Street 1:100 VILLAGE SQ
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1820
Practice Address - Country:US
Practice Address - Phone:314-355-4010
Practice Address - Fax:314-355-9484
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105736207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO246971709Medicaid
MO002013335Medicare ID - Type Unspecified
MO246971709Medicaid