Provider Demographics
NPI:1154371706
Name:MARK G. HAYWOOD, MD, LLC
Entity type:Organization
Organization Name:MARK G. HAYWOOD, MD, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-442-1161
Mailing Address - Street 1:721 WELLNESS WAY
Mailing Address - Street 2:STE 210
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-3304
Mailing Address - Country:US
Mailing Address - Phone:678-442-1161
Mailing Address - Fax:678-442-9967
Practice Address - Street 1:721 WELLNESS WAY
Practice Address - Street 2:STE 210
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3304
Practice Address - Country:US
Practice Address - Phone:678-442-1161
Practice Address - Fax:678-442-9967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035898207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7296Medicare ID - Type Unspecified
GA5623180001Medicare NSC