Provider Demographics
NPI:1508836917
Name:HAINES, J. GLENN (MD)
Entity Type:Individual
Prefix:
First Name:J.
Middle Name:GLENN
Last Name:HAINES
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 1:1830 WELLS ST
Mailing Address - Street 2:STE 101
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2365
Mailing Address - Country:US
Mailing Address - Phone:808-244-3200
Mailing Address - Fax:808-244-9793
Practice Address - Street 1:1830 WELLS ST
Practice Address - Street 2:STE 101
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2365
Practice Address - Country:US
Practice Address - Phone:808-244-3200
Practice Address - Fax:808-244-9793
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3041208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HICS8366OtherMEDICARE RAILROAD
HIDJ173YMedicare PIN
HIH0000BDFKCMedicare ID - Type Unspecified
HIE76872Medicare UPIN