Provider Demographics
NPI:1174592877
Name:HATTAN, DEAN H (OD)
Entity type:Individual
Prefix:
First Name:DEAN
Middle Name:H
Last Name:HATTAN
Suffix:
Gender:M
Credentials:OD
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 130
Mailing Address - Street 2:
Mailing Address - City:SAN FIDEL
Mailing Address - State:NM
Mailing Address - Zip Code:87049-0130
Mailing Address - Country:US
Mailing Address - Phone:505-552-5300
Mailing Address - Fax:505-552-5811
Practice Address - Street 1:80 B VETERANS BLVD
Practice Address - Street 2:I-40, EXIT 102
Practice Address - City:ACOMA
Practice Address - State:NM
Practice Address - Zip Code:87034
Practice Address - Country:US
Practice Address - Phone:505-552-5300
Practice Address - Fax:505-552-5811
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA001231152W00000X
AZ2106152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH3450Medicaid
NMH3450Medicaid
NM320070Medicare Oscar/Certification