Provider Demographics
NPI:1487749412
Name:HAWTHORNE, COLETTE (MD)
Entity type:Individual
Prefix:DR
First Name:COLETTE
Middle Name:
Last Name:HAWTHORNE
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 1:1833 BOULEVARD STREET
Mailing Address - Street 2:NORTH FLORIDA/SOUTH GEORGIA VETERANS HEALTH SYSTEM
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206
Mailing Address - Country:US
Mailing Address - Phone:904-232-2751
Mailing Address - Fax:
Practice Address - Street 1:1833 BOULEVARD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-4382
Practice Address - Country:US
Practice Address - Phone:904-232-2751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25937207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64259377Medicaid
KY64259377Medicaid
KYE01384Medicare UPIN