Basic Information
| Provider Information | |||||||||
| NPI: | 1568874824 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEAD | ||||||||
| FirstName: | HAYDEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROAN | ||||||||
| OtherFirstName: | HAYDEN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3203 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LINDALE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757717727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9032664000 | ||||||||
| FaxNumber: | 9038775080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2014 | ||||||||
| LastUpdateDate: | 10/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | BP10050113 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | R0585 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 587636YMAF | 01 | TX | MEDICARE | OTHER | 75-2616977-028 | 01 | TX | TRICARE | OTHER | P01878872 | 01 | TX | MEDICARE RAIL ROAD | OTHER | 374159701 | 01 | TX | MEDICAID | OTHER |