Basic Information
| Provider Information | |||||||||
| NPI: | 1154617496 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHAZRIK | ||||||||
| FirstName: | HAKAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 102222 | ||||||||
| Address2: | ATTN CREDENTIALING | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392748500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4100 WATERMAN WAY | ||||||||
| Address2: | |||||||||
| City: | TAVARES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327785270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523431117 | ||||||||
| FaxNumber: | 8664452968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2011 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | ME157856 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 114745800 | 05 | FL | MEDICAID |