Provider Demographics
NPI:1770839979
Name:HATLEY, JONATHAN MATTHEW (OD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MATTHEW
Last Name:HATLEY
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 1:102 W CLAY RD
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-8302
Mailing Address - Country:US
Mailing Address - Phone:918-519-4345
Mailing Address - Fax:
Practice Address - Street 1:900 N OWEN WALTERS BLVD
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:OK
Practice Address - Zip Code:74365-5003
Practice Address - Country:US
Practice Address - Phone:918-434-8516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-25
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2734152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist