Provider Demographics
NPI:1265402911
Name:HATCH, RUSTIN M (OD)
Entity type:Individual
Prefix:DR
First Name:RUSTIN
Middle Name:M
Last Name:HATCH
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:526 SHOUP AVE W
Mailing Address - Street 2:STE H
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301
Mailing Address - Country:US
Mailing Address - Phone:208-733-2400
Mailing Address - Fax:208-734-0343
Practice Address - Street 1:526 SHOUP AVE W
Practice Address - Street 2:STE H
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-733-2400
Practice Address - Fax:208-734-0343
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDODP-100048152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806835700Medicaid
U99805Medicare UPIN
1104280001Medicare NSC