Healthcare Provider Details

I. General information

NPI: 1093211955
Provider Name (Legal Business Name): MAXWELL MARTIN HAYDEN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2018
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N MARKET ST
SPARTA IL
62286-1048
US

IV. Provider business mailing address

PO BOX 297
SPARTA IL
62286-0297
US

V. Phone/Fax

Practice location:
  • Phone: 618-443-4138
  • Fax: 618-443-2956
Mailing address:
  • Phone: 618-443-1337
  • Fax: 618-443-1383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016005867
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: