Healthcare Provider Details

I. General information

NPI: 1235131269
Provider Name (Legal Business Name): BRYAN SMITH HATHORN M D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 HENNESSY BLVD SUITE 1000
BATON ROUGE LA
70808-4300
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 225-767-3900
  • Fax: 225-766-2226
Mailing address:
  • Phone: 225-765-5727
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number14857R
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number14857R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: