Provider Demographics
NPI:1154617496
Name:KHAZRIK, HAKAM (MD)
Entity type:Individual
Prefix:DR
First Name:HAKAM
Middle Name:
Last Name:KHAZRIK
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 102222
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8500
Mailing Address - Fax:
Practice Address - Street 1:4100 WATERMAN WAY
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5270
Practice Address - Country:US
Practice Address - Phone:352-343-1117
Practice Address - Fax:866-445-2968
Is Sole Proprietor?:No
Enumeration Date:2011-06-24
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME157856207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114745800Medicaid