Provider Demographics
NPI:1568482701
Name:HAZEN, JUSTIN LYELL (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LYELL
Last Name:HAZEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4411 MONTANO RD NW
Mailing Address - Street 2:SUITE F
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-3235
Mailing Address - Country:US
Mailing Address - Phone:505-899-4414
Mailing Address - Fax:505-898-2395
Practice Address - Street 1:4411 MONTANO RD NW
Practice Address - Street 2:SUITE F
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-3235
Practice Address - Country:US
Practice Address - Phone:505-899-4414
Practice Address - Fax:505-898-2395
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2014-03-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NM2004-0125207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMI23863Medicare UPIN