Provider Demographics
NPI:1750365177
Name:HAWTHORNE, HORACE A (DO)
Entity type:Individual
Prefix:DR
First Name:HORACE
Middle Name:A
Last Name:HAWTHORNE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:380 NASSAU RD
Mailing Address - Street 2:LONG ISLAND FQHC, INC.
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-1343
Mailing Address - Country:US
Mailing Address - Phone:516-571-8600
Mailing Address - Fax:
Practice Address - Street 1:101 S BERGEN PL
Practice Address - Street 2:LONG ISLAND FQHC, INC.
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3528
Practice Address - Country:US
Practice Address - Phone:516-623-3600
Practice Address - Fax:516-623-9191
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY228249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02483549Medicaid
I01285Medicare UPIN
NY02483549Medicaid