Provider Demographics
NPI:1730187824
Name:HATHAWAY, PETER BLAINE (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:BLAINE
Last Name:HATHAWAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25488
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0488
Mailing Address - Country:US
Mailing Address - Phone:800-475-3698
Mailing Address - Fax:801-296-6199
Practice Address - Street 1:1433 N 1075 W STE 104
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2746
Practice Address - Country:US
Practice Address - Phone:801-298-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT372564-12052085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8067535Medicaid
NV002089152Medicaid
UTP00196218OtherRR MEDICARE
WY120828400Medicaid
CA4456436Medicaid
AZ927733Medicaid
UTP00651533OtherRR MEDICARE
UTD2916Medicaid
AZ927733Medicaid
UT005783001Medicare PIN
UTP00651533OtherRR MEDICARE