Provider Demographics
NPI:1801191960
Name:SAMUEL HATHY III,O.D.
Entity Type:Organization
Organization Name:SAMUEL HATHY III,O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HATHY
Authorized Official - Suffix:III
Authorized Official - Credentials:OD
Authorized Official - Phone:904-292-3976
Mailing Address - Street 1:11111-44 SAN JOSE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL-OPC-2361332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20163Medicare PIN
FLU05440Medicare UPIN