Provider Demographics
NPI:1699889121
Name:HIATT, EDWIN LEE (MD)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:LEE
Last Name:HIATT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:EDWIN
Other - Middle Name:LEE
Other - Last Name:HIATT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:511 W COTTON AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:31636-6601
Mailing Address - Country:US
Mailing Address - Phone:229-559-7611
Mailing Address - Fax:
Practice Address - Street 1:2841 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1743
Practice Address - Country:US
Practice Address - Phone:229-293-0132
Practice Address - Fax:229-293-0162
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12920207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAVA0000Medicare UPIN