Provider Demographics
NPI:1255744272
Name:HATHAWAY, TAYLOR JOSEPH (DO)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:JOSEPH
Last Name:HATHAWAY
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 1:2114 N FLAMINGO RD # 2100
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-3501
Mailing Address - Country:US
Mailing Address - Phone:754-247-1213
Mailing Address - Fax:
Practice Address - Street 1:3200 W QUAYSIDE DR
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33026-3789
Practice Address - Country:US
Practice Address - Phone:754-247-1213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS14641208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020815500Medicaid