Provider Demographics
NPI:1164489373
Name:HATHAWAY, GARY S (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:S
Last Name:HATHAWAY
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 1:590 NANCY ST NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1334
Mailing Address - Country:US
Mailing Address - Phone:770-423-0395
Mailing Address - Fax:770-499-0352
Practice Address - Street 1:590 NANCY ST NW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1334
Practice Address - Country:US
Practice Address - Phone:770-423-0395
Practice Address - Fax:770-499-0352
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042599208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52636051-004OtherBC/BS ID
GA565113OtherAETNA HMO
GA5647403OtherAETNA PPO ID
GA00744961DMedicaid
GA020042822OtherRAILROAD MEDICARE ID
GA565113OtherAETNA HMO
GA5647403OtherAETNA PPO ID