Provider Demographics
NPI:1700885811
Name:HATTEN, HOMER PAUL JR (MD)
Entity Type:Individual
Prefix:
First Name:HOMER
Middle Name:PAUL
Last Name:HATTEN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 TWIN ISLAND REACH
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-3909
Mailing Address - Country:US
Mailing Address - Phone:772-231-3453
Mailing Address - Fax:772-231-8986
Practice Address - Street 1:1485 37TH ST
Practice Address - Street 2:SUITE 107
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6500
Practice Address - Country:US
Practice Address - Phone:772-569-9745
Practice Address - Fax:772-567-6868
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00766792085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262748500Medicaid
FL61947Medicare ID - Type Unspecified
D93585Medicare UPIN