Provider Demographics
NPI:1659577021
Name:HATHAWAY, MARK LEE (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:LEE
Last Name:HATHAWAY
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 SKIBO RD
Mailing Address - Street 2:STE 148
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303
Mailing Address - Country:US
Mailing Address - Phone:910-487-1863
Mailing Address - Fax:910-487-5018
Practice Address - Street 1:1800 SKIBO RD
Practice Address - Street 2:STE 148
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303
Practice Address - Country:US
Practice Address - Phone:910-487-1863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC335156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician