Provider Demographics
NPI:1487755617
Name:HATHORN, LANDALL CLARK (MD)
Entity type:Individual
Prefix:
First Name:LANDALL
Middle Name:CLARK
Last Name:HATHORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:601-200-4760
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:1050 RIVER OAKS DR STE 100
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9564
Practice Address - Country:US
Practice Address - Phone:601-200-4760
Practice Address - Fax:601-200-4742
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18385207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05408094Medicaid
MS05408094Medicaid
MS302I084157Medicare PIN