Provider Demographics
NPI:1922105220
Name:HAYCRAFT, GORDON L (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:L
Last Name:HAYCRAFT
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 1:2922 PARK WEST HTS
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5006
Mailing Address - Country:US
Mailing Address - Phone:573-331-7850
Mailing Address - Fax:
Practice Address - Street 1:1723 BROADWAY
Practice Address - Street 2:SUITE 310
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701
Practice Address - Country:US
Practice Address - Phone:573-331-7850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9D76207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
E35618Medicare UPIN