Provider Demographics
NPI:1235131269
Name:HATHORN, BRYAN SMITH (M D)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:SMITH
Last Name:HATHORN
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-765-5727
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:SUITE 1000
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-767-3900
Practice Address - Fax:225-766-2226
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14857R207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5355641OtherAETNA
LA232799OtherWELLCARE
LA2500911OtherUNITED HEALTH CARE
LA060070427OtherPALMETTO GBA
LA1149551Medicaid
LA5355641OtherAETNA
LA2500911OtherUNITED HEALTH CARE