Provider Demographics
NPI:1306266291
Name:HAZEN FAMILY EYECARE PC
Entity type:Organization
Organization Name:HAZEN FAMILY EYECARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:CZYWCZYNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-516-2115
Mailing Address - Street 1:104 12TH AVE NW
Mailing Address - Street 2:SUITE #1
Mailing Address - City:HAZEN
Mailing Address - State:ND
Mailing Address - Zip Code:58545-4100
Mailing Address - Country:US
Mailing Address - Phone:701-748-5220
Mailing Address - Fax:701-748-5221
Practice Address - Street 1:104 12TH AVE NW
Practice Address - Street 2:SUITE #1
Practice Address - City:HAZEN
Practice Address - State:ND
Practice Address - Zip Code:58545-4100
Practice Address - Country:US
Practice Address - Phone:701-748-5220
Practice Address - Fax:701-748-5221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND681152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60698Medicaid
ND12122586OtherCAQH
ND1427281583OtherOPTOMETRIST NPI
ND681OtherSTATE LICENSE NUMBER
ND681OtherSTATE LICENSE NUMBER
ND681OtherSTATE LICENSE NUMBER