Healthcare Provider Details

I. General information

NPI: 1649166323
Provider Name (Legal Business Name): MITCHELL D HALEY OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2025
Last Update Date: 07/01/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3302 NE STALLINGS DR
NACOGDOCHES TX
75965-8727
US

IV. Provider business mailing address

3302 NE STALLINGS DR
NACOGDOCHES TX
75965-8727
US

V. Phone/Fax

Practice location:
  • Phone: 936-564-3600
  • Fax: 936-564-3770
Mailing address:
  • Phone: 936-564-3600
  • Fax: 936-564-3770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11435
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: