Basic Information
| Provider Information | |||||||||
| NPI: | 1679872238 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAYNES | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 S. MAIN ST. | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92882 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1127 WILSHIRE BLVD STE 805 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900173909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2139771176 | ||||||||
| FaxNumber: | 2139770668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2011 | ||||||||
| LastUpdateDate: | 02/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MD 60491830 | WA | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | A147715 | CA | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.