Provider Demographics
NPI:1194721001
Name:HAYNES, MICHAEL L (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:HAYNES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 MASON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5103
Mailing Address - Country:US
Mailing Address - Phone:386-274-5525
Mailing Address - Fax:386-274-5585
Practice Address - Street 1:1900 MASON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5103
Practice Address - Country:US
Practice Address - Phone:386-274-5525
Practice Address - Fax:386-274-5585
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP1839152W00000X
FLOPC1839152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078920801Medicaid
FL21851OtherBCBS
FL21851OtherBCBS
FL078920801Medicaid