Provider Demographics
NPI:1104116300
Name:HATHCOCK, SARAH JAYNE (MD)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:JAYNE
Last Name:HATHCOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:1635 BLUE SPRUCE DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-5427
Practice Address - Country:US
Practice Address - Phone:303-697-2583
Practice Address - Fax:970-494-4050
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-10
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0059037208000000X
LAMD.206770208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000155574Medicaid
LA2147838Medicaid
LA356146YH3UMedicare PIN