Provider Demographics
NPI:1083962781
Name:SUZANNE M HAZEN PC
Entity Type:Organization
Organization Name:SUZANNE M HAZEN PC
Other - Org Name:TELLURIDE VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:MCLEAN
Authorized Official - Last Name:HAZEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-708-4890
Mailing Address - Street 1:PO BOX 3110
Mailing Address - Street 2:
Mailing Address - City:TELLURIDE
Mailing Address - State:CO
Mailing Address - Zip Code:81435-3110
Mailing Address - Country:US
Mailing Address - Phone:970-708-4890
Mailing Address - Fax:970-728-8987
Practice Address - Street 1:220 E COLORADO AVE 210
Practice Address - Street 2:
Practice Address - City:TELLURIDE
Practice Address - State:CO
Practice Address - Zip Code:81435
Practice Address - Country:US
Practice Address - Phone:970-708-4890
Practice Address - Fax:970-728-8987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12002267Medicaid
CO12002267Medicaid