Provider Demographics
NPI:1184735151
Name:HAYNES, WILLIAM MARK (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MARK
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:PO BOX 29
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:LA
Mailing Address - Zip Code:71040-0029
Mailing Address - Country:US
Mailing Address - Phone:318-927-3571
Mailing Address - Fax:318-927-2677
Practice Address - Street 1:912 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:LA
Practice Address - Zip Code:71040-3328
Practice Address - Country:US
Practice Address - Phone:318-927-3571
Practice Address - Fax:318-927-2677
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017831207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1347086Medicaid
LA1347086Medicaid
LAE56195Medicare UPIN