Provider Demographics
NPI:1669739397
Name:WALTER HATHAWAY, O.D.
Entity type:Organization
Organization Name:WALTER HATHAWAY, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:REMONIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:ALDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-385-0255
Mailing Address - Street 1:255 JOHN KNOX RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-6676
Mailing Address - Country:US
Mailing Address - Phone:850-385-0255
Mailing Address - Fax:850-385-3941
Practice Address - Street 1:255 JOHN KNOX RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-6676
Practice Address - Country:US
Practice Address - Phone:850-385-0255
Practice Address - Fax:850-385-3941
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALTER HATHAWAY, O.D.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC860152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084900600Medicaid
FL084900600Medicaid
FL20141Medicare PIN