Provider Demographics
NPI:1720068133
Name:HATHAWAY, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:HATHAWAY
Suffix:
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:PO BOX 418498
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-8498
Mailing Address - Country:US
Mailing Address - Phone:703-558-1544
Mailing Address - Fax:
Practice Address - Street 1:110 IRVING ST NW
Practice Address - Street 2:SUITE 5B-33
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2976
Practice Address - Country:US
Practice Address - Phone:202-877-7028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD21559207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC025687900Medicaid
DC759210800Medicaid
DC025687900Medicaid
DC759210800Medicaid