Provider Demographics
NPI:1689738973
Name:HAVERLAH, GENE V (MD)
Entity Type:Individual
Prefix:
First Name:GENE
Middle Name:V
Last Name:HAVERLAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:HC BOX 28F HWY 90 WEST
Mailing Address - Street 2:
Mailing Address - City:DEL RIO
Mailing Address - State:TX
Mailing Address - Zip Code:78840
Mailing Address - Country:US
Mailing Address - Phone:830-774-5534
Mailing Address - Fax:830-775-7325
Practice Address - Street 1:913 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-5807
Practice Address - Country:US
Practice Address - Phone:830-774-5534
Practice Address - Fax:830-775-7525
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXC6978207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB23356Medicare UPIN