Provider Demographics
NPI:1619694882
Name:HAINES, WILLIAM OTIS
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:OTIS
Last Name:HAINES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9433 BOBCAT TRL
Mailing Address - Street 2:
Mailing Address - City:LEO
Mailing Address - State:IN
Mailing Address - Zip Code:46765-9360
Mailing Address - Country:US
Mailing Address - Phone:260-437-4643
Mailing Address - Fax:
Practice Address - Street 1:770 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2056
Practice Address - Country:US
Practice Address - Phone:260-451-8242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN45023378A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program