Provider Demographics
NPI:1134221419
Name:HATHCOCK, STEPHEN SCOTT (DO)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:SCOTT
Last Name:HATHCOCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 EARL FRYE BLVD
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-5500
Mailing Address - Country:US
Mailing Address - Phone:662-256-7111
Mailing Address - Fax:662-257-6775
Practice Address - Street 1:1105 EARL FRYE BLVD
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-5500
Practice Address - Country:US
Practice Address - Phone:662-256-7111
Practice Address - Fax:662-257-6775
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18079207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05183339Medicaid
H62602Medicare Oscar/Certification
MS080003787Medicare Oscar/Certification
MS080003787Medicare ID - Type Unspecified
MS05183339Medicaid