Provider Demographics
NPI:1679691885
Name:HATTAWAY, KEVIN (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:HATTAWAY
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 1:525 HATHAWAY STREET
Mailing Address - Street 2:
Mailing Address - City:FAIRPLAY
Mailing Address - State:CO
Mailing Address - Zip Code:80440
Mailing Address - Country:US
Mailing Address - Phone:303-788-9220
Mailing Address - Fax:
Practice Address - Street 1:525 HATHAWAY STREET
Practice Address - Street 2:
Practice Address - City:FAIRPLAY
Practice Address - State:CO
Practice Address - Zip Code:80440
Practice Address - Country:US
Practice Address - Phone:303-788-9220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30152207Q00000X
CODR.0049308207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
3150572OtherBCBS
3825738Medicare ID - Type Unspecified
TNG82186Medicare UPIN