Provider Demographics
NPI:1093893752
Name:HATHAWAY, ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:ANN
Middle Name:
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 MAHOGANY DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3132
Mailing Address - Country:US
Mailing Address - Phone:415-472-6849
Mailing Address - Fax:415-446-0118
Practice Address - Street 1:25 MITCHELL BLVD
Practice Address - Street 2:#3
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2007
Practice Address - Country:US
Practice Address - Phone:415-499-0966
Practice Address - Fax:415-446-0118
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42615207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G426151Medicaid
CAF44320Medicare UPIN
CA00G426151Medicare ID - Type Unspecified