Provider Demographics
NPI:1528094729
Name:HAYDOCK, RICHARD TERRELL (CRNA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:TERRELL
Last Name:HAYDOCK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POST OFFICE BOX 22926
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225
Mailing Address - Country:US
Mailing Address - Phone:713-400-2990
Mailing Address - Fax:713-400-2993
Practice Address - Street 1:1635 NORTH LOOP WEST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1593
Practice Address - Country:US
Practice Address - Phone:713-400-2990
Practice Address - Fax:713-400-2993
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRN646443367500000X
TX646443367500000X
TXAP115110367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1792683OtherLOUISIANA MEDICAID
P00611251OtherMEDICARE RAILROAD
TX86588UOtherBCBS
LA1792683OtherLOUISIANA MEDICAID