Healthcare Provider Details

I. General information

NPI: 1619961729
Provider Name (Legal Business Name): GARY R HATTAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 03/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 NEBRASKA ST
SIOUX CITY IA
51104
US

IV. Provider business mailing address

PO BOX 5410
SIOUX CITY IA
51102
US

V. Phone/Fax

Practice location:
  • Phone: 712-252-2477
  • Fax: 712-252-5516
Mailing address:
  • Phone: 712-252-2477
  • Fax: 712-252-5516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31287
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: