Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | ME43394 | FL |
NPI | 1013061456 |
---|---|
Provider Name | Donald Brent Hayden |
First Address | Lake City, FL 32025-0453 |
Second Address | Lake City, FL 32025-0453 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/01/2007 |
Last Update Date | 11/08/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
041891900 | (05) | FL |
E34632 | (02) |