Provider Demographics
NPI:1790735587
Name:HAYNES, STEPHEN H (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:H
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 1:1937 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4025
Mailing Address - Country:US
Mailing Address - Phone:575-763-5585
Mailing Address - Fax:575-763-6051
Practice Address - Street 1:1937 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:575-763-5585
Practice Address - Fax:575-763-6051
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM82-61208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM19018Medicaid
NMP00347709OtherRAILROAD MEDICARE PIN
C97826Medicare UPIN
NM19018Medicaid