Provider Demographics
NPI:1720154099
Name:HATHAWAY, CHARLES WALTER (OD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WALTER
Last Name:HATHAWAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 JOHN KNOX RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-6676
Mailing Address - Country:US
Mailing Address - Phone:850-385-0255
Mailing Address - Fax:850-385-3941
Practice Address - Street 1:255 JOHN KNOX RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-6676
Practice Address - Country:US
Practice Address - Phone:850-385-0255
Practice Address - Fax:850-385-3941
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC860152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084900600Medicaid
FLT83945Medicare UPIN
FL20141Medicare PIN