Provider Demographics
NPI:1003098161
Name:HAZIN, MOUSTAFA I (DO)
Entity Type:Individual
Prefix:
First Name:MOUSTAFA
Middle Name:I
Last Name:HAZIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE 56765
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-6765
Mailing Address - Country:US
Mailing Address - Phone:602-999-3637
Mailing Address - Fax:602-406-6132
Practice Address - Street 1:500 W THOMAS RD
Practice Address - Street 2:SUITE 900
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4224
Practice Address - Country:US
Practice Address - Phone:602-406-5590
Practice Address - Fax:602-406-7165
Is Sole Proprietor?:No
Enumeration Date:2007-11-30
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5461207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ529073Medicaid
AZ529073Medicaid