Provider Demographics
NPI:1790754919
Name:HATHAWAY, KENNETH J (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:HATHAWAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 KINGSTOWN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NARRAGANSETT
Mailing Address - State:RI
Mailing Address - Zip Code:02882-3239
Mailing Address - Country:US
Mailing Address - Phone:401-783-3334
Mailing Address - Fax:401-783-9270
Practice Address - Street 1:360 KINGSTOWN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:NARRAGANSETT
Practice Address - State:RI
Practice Address - Zip Code:02882-3239
Practice Address - Country:US
Practice Address - Phone:401-783-3334
Practice Address - Fax:401-783-9270
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDO278207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9003623Medicaid
RI3623OtherFEDERAL BLUE CROSS
RI050389568OtherUNITEDHEALTHCARE
RI3623-2OtherBLUE CROSS OF RHODE ISLAN
RI007060241Medicare PIN
RI050389568OtherUNITEDHEALTHCARE