Provider Demographics
NPI:1588756209
Name:HATHAWAY, ELAINE GREEN (MD)
Entity type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:GREEN
Last Name:HATHAWAY
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 1:317 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08904-1817
Mailing Address - Country:US
Mailing Address - Phone:732-828-5190
Mailing Address - Fax:732-828-0677
Practice Address - Street 1:317 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:08904-1817
Practice Address - Country:US
Practice Address - Phone:732-828-5190
Practice Address - Fax:732-828-0677
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA06237200207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC24436Medicare UPIN
NJ106627L5HMedicare ID - Type Unspecified