Provider Demographics
NPI:1912999475
Name:HAYNIE, GARY MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:MICHAEL
Last Name:HAYNIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1534 ELIZABETH AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4531
Mailing Address - Country:US
Mailing Address - Phone:318-629-5001
Mailing Address - Fax:318-629-5020
Practice Address - Street 1:1500 LINE AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-635-3052
Practice Address - Fax:318-632-6087
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16336207X00000X
LA016336207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAC68471Medicare UPIN
LA5M340B103Medicare PIN
LA200016734Medicare PIN
5M340B103Medicare PIN