Provider Demographics
NPI:1043564586
Name:HAZRAT, EHSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:EHSAN
Middle Name:
Last Name:HAZRAT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE
Mailing Address - Street 2:DEPT 358
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9324
Mailing Address - Country:US
Mailing Address - Phone:541-767-5200
Mailing Address - Fax:541-767-5353
Practice Address - Street 1:1515 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-9700
Practice Address - Country:US
Practice Address - Phone:541-767-5200
Practice Address - Fax:541-767-5353
Is Sole Proprietor?:No
Enumeration Date:2012-11-06
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125062419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine