Provider Demographics
NPI:1053362541
Name:HAYCOCK, DARRYL MITCHELL (DPM)
Entity type:Individual
Prefix:DR
First Name:DARRYL
Middle Name:MITCHELL
Last Name:HAYCOCK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 BATON ROUGE
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-1129
Mailing Address - Country:US
Mailing Address - Phone:419-228-3338
Mailing Address - Fax:419-228-3334
Practice Address - Street 1:2311 BATON ROUGE
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-1129
Practice Address - Country:US
Practice Address - Phone:419-228-3338
Practice Address - Fax:419-228-3334
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002946213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2094951Medicaid
OHHA0859395Medicare ID - Type Unspecified
OH5654010001Medicare NSC
OHU72571Medicare UPIN