Provider Demographics
NPI:1073545588
Name:HATHORN, JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:HATHORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12670
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71315-2670
Mailing Address - Country:US
Mailing Address - Phone:800-639-2519
Mailing Address - Fax:985-447-8556
Practice Address - Street 1:3330 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3841
Practice Address - Country:US
Practice Address - Phone:800-639-2519
Practice Address - Fax:985-447-8556
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13632R207P00000X
TXM6179207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1435279Medicaid
TX8J9143Medicare PIN
LA1435279Medicaid
LA5H994Medicare ID - Type Unspecified
LAH30562Medicare UPIN
H30562Medicare UPIN