Basic Information
Provider Information | |||||||||
NPI: | 1770825275 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAZLETON | ||||||||
FirstName: | KEITH | ||||||||
MiddleName: | ZACHARY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD, PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1625 N CAMPBELL AVE # 245073 | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857194330 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206945437 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 535 N WILMOT RD STE 101 | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857112683 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206945437 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/22/2013 | ||||||||
LastUpdateDate: | 07/26/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/26/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X | DR.0055436 | CO | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | 2080P0206X | 61253 | AZ | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | 2080T0004X | DR.0055436 | CO | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Transplant Hepatology | 2080T0004X | 61253 | AZ | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Transplant Hepatology |
No ID Information.