Provider Demographics
NPI:1760507875
Name:HAYNES, HENRY D (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:D
Last Name:HAYNES
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 1:50 TREMONT ST
Mailing Address - Street 2:#101
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-2721
Mailing Address - Country:US
Mailing Address - Phone:781-665-3500
Mailing Address - Fax:781-665-0658
Practice Address - Street 1:50 TREMONT ST
Practice Address - Street 2:#101
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-2721
Practice Address - Country:US
Practice Address - Phone:781-665-3500
Practice Address - Fax:781-665-0658
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA30455208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9741992Medicaid
MAB97047Medicare UPIN
MAM13673Medicare ID - Type Unspecified