Provider Demographics
NPI:1073600110
Name:HATHAWAY, ELIZABETH B (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:B
Last Name:HATHAWAY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6874 GAULKE CIR
Mailing Address - Street 2:
Mailing Address - City:HAZELHURST
Mailing Address - State:WI
Mailing Address - Zip Code:54531-3500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6874 GAULKE CIR
Practice Address - Street 2:
Practice Address - City:HAZELHURST
Practice Address - State:WI
Practice Address - Zip Code:54531-3500
Practice Address - Country:US
Practice Address - Phone:615-480-7410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67842207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F68573Medicare UPIN