Provider Demographics
NPI:1427196435
Name:HATHY, SAMUEL III (OD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:HATHY
Suffix:III
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 1:11111 SAN JOSE BLVD STE 44
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-7274
Mailing Address - Country:US
Mailing Address - Phone:904-292-3976
Mailing Address - Fax:904-292-5322
Practice Address - Street 1:11111 SAN JOSE BLVD STE 44
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-7274
Practice Address - Country:US
Practice Address - Phone:904-292-3976
Practice Address - Fax:904-292-5322
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2361152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU05440Medicare UPIN