Healthcare Provider Details

I. General information

NPI: 1700885811
Provider Name (Legal Business Name): HOMER PAUL HATTEN JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 06/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 37TH ST SUITE 107
VERO BEACH FL
32960-6500
US

IV. Provider business mailing address

111 TWIN ISLAND REACH
VERO BEACH FL
32963-3909
US

V. Phone/Fax

Practice location:
  • Phone: 772-569-9745
  • Fax: 772-567-6868
Mailing address:
  • Phone: 772-231-3453
  • Fax: 772-231-8986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberME0076679
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME0076679
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: