1841360302 NPI number — DR. JAY M HAYNIE O.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841360302 NPI number — DR. JAY M HAYNIE O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAYNIE
Provider First Name:
JAY
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841360302
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2914 S ALDER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98409-4819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-272-9245
Provider Business Mailing Address Fax Number:
253-272-9413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2914 S ALDER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98409-4819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-272-9245
Provider Business Practice Location Address Fax Number:
253-272-9413
Provider Enumeration Date:
11/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OD00003026 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: OD508WA . This is a "ALASKA MEDICAID" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 4341610 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1244341 . This is a "COVENTRY HEALTH CARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2021996 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 157763 . This is a "LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1244341 . This is a "FIRST CHOICE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: AMIWA51620 . This is a "MOLINA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 4746291 . This is a "CIGNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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