MEDICARE: DR. MOLLIE ANN HIATT O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1419	NE

General Provider Information

NPI Number	:	1326454414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MOLLIE ANN HIATT O.D.

Provider Business Mailing Address
First Line	:	17838 BURKE ST STE 100
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68118-2256
Country	:	US
Telephone Number	:	402-558-2211
Fax Number	:	402-558-2212

Provider Business Practice Location Address
First Line	:	17838 BURKE ST STE 100
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68118-2256
Country	:	US
Telephone Number	:	402-558-2211
Fax Number	:	402-558-2212

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2014
Last Update Date	:	09/18/2018

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