Provider Demographics
NPI:1104998723
Name:HAZEN, ROBERT (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:HAZEN
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 LIMESTONE RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-1928
Mailing Address - Country:US
Mailing Address - Phone:302-998-0551
Mailing Address - Fax:302-998-0877
Practice Address - Street 1:4750 LIMESTONE RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-1928
Practice Address - Country:US
Practice Address - Phone:302-998-0551
Practice Address - Fax:302-998-0877
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE1991073141156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0303550001Medicare NSC