Provider Demographics
NPI:1295744399
Name:HAIRSTON, WILLIAM WAYNE (DO)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:WAYNE
Last Name:HAIRSTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 N MOUND ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4027
Mailing Address - Country:US
Mailing Address - Phone:936-568-8425
Mailing Address - Fax:
Practice Address - Street 1:1002 N MOUND ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4437
Practice Address - Country:US
Practice Address - Phone:936-560-3800
Practice Address - Fax:936-560-0102
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE5773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101237902Medicaid
TX87A836Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER
TX101237902Medicaid