Provider Demographics
NPI:1811971658
Name:HAWKLEY, REDGE MONTE (DPM)
Entity type:Individual
Prefix:DR
First Name:REDGE
Middle Name:MONTE
Last Name:HAWKLEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 FOUNDATION LN
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-9206
Mailing Address - Country:US
Mailing Address - Phone:530-872-3038
Mailing Address - Fax:530-872-8685
Practice Address - Street 1:1806 FOUNDATION LN
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-9206
Practice Address - Country:US
Practice Address - Phone:530-872-3038
Practice Address - Fax:530-872-8685
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2424213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E24240Medicaid
CA000E24240Medicare ID - Type Unspecified
CA000E24240Medicaid