Provider Demographics
NPI:1952445595
Name:MICHAEL S HAVERTY MD INC
Entity Type:Organization
Organization Name:MICHAEL S HAVERTY MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:HAVERTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-348-3910
Mailing Address - Street 1:2342 PROFESSIONAL PKWY
Mailing Address - Street 2:SUITE 260
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-1629
Mailing Address - Country:US
Mailing Address - Phone:805-348-3950
Mailing Address - Fax:805-348-9301
Practice Address - Street 1:2342 PROFESSIONAL PKWY
Practice Address - Street 2:SUITE 260
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-1629
Practice Address - Country:US
Practice Address - Phone:805-348-3950
Practice Address - Fax:805-348-9301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53646207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W21477Medicare PIN