Healthcare Provider Details

I. General information

NPI: 1043403249
Provider Name (Legal Business Name): JOHN HALEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 4TH STREET SUITE 4B174
LUBBOCK TX
79430-9406
US

IV. Provider business mailing address

PO BOX 5865
LUBBOCK TX
79408-5865
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-7337
  • Fax: 806-743-4218
Mailing address:
  • Phone: 806-743-2898
  • Fax: 806-743-2787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN2546
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: