Provider Demographics
NPI:1043847627
Name:HATHAWAY, MILLIE MAE (DO)
Entity Type:Individual
Prefix:
First Name:MILLIE MAE
Middle Name:
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 MONTE VISTA AVE STE 260
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-6604
Mailing Address - Country:US
Mailing Address - Phone:909-630-7938
Mailing Address - Fax:909-469-2118
Practice Address - Street 1:1601 MONTE VISTA AVE STE 100
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-6601
Practice Address - Country:US
Practice Address - Phone:909-630-7938
Practice Address - Fax:909-469-2118
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A20053207Q00000X
CA20A50053207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine