Provider Demographics
NPI:1770693558
Name:HATHAWAY, WILMIE (DO)
Entity type:Individual
Prefix:
First Name:WILMIE
Middle Name:
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 LAGUNA HONDA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-1411
Mailing Address - Country:US
Mailing Address - Phone:415-682-5952
Mailing Address - Fax:
Practice Address - Street 1:375 LAGUNA HONDA BLVD
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94116-1411
Practice Address - Country:US
Practice Address - Phone:415-682-5952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9378207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TH8497Medicare UPIN
CA020A93780Medicare ID - Type Unspecified