Provider Demographics
NPI:1477730083
Name:HATHAWAY, DAVID (CPED)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:HATHAWAY
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7410 WORNALL RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-1540
Mailing Address - Country:US
Mailing Address - Phone:800-471-8592
Mailing Address - Fax:
Practice Address - Street 1:7410 WORNALL RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-1540
Practice Address - Country:US
Practice Address - Phone:800-471-8592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-25
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2899211D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes211D00000XPodiatric Medicine & Surgery Service ProvidersAssistant, Podiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE2899OtherBOARD PEDORTHICS