Provider Demographics
NPI:1578831004
Name:HAYWOOD, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HAYWOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1273
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-1273
Mailing Address - Country:US
Mailing Address - Phone:817-235-2537
Mailing Address - Fax:
Practice Address - Street 1:44521 504TH AVE
Practice Address - Street 2:
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-2064
Practice Address - Country:US
Practice Address - Phone:817-235-2537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200305190BMedicaid