Provider Demographics
NPI:1114183738
Name:GALICIA, HAZEL A (DO)
Entity Type:Individual
Prefix:DR
First Name:HAZEL
Middle Name:A
Last Name:GALICIA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307-09 S. CICERO AVE.
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-2452
Mailing Address - Country:US
Mailing Address - Phone:708-780-9777
Mailing Address - Fax:708-780-9787
Practice Address - Street 1:2307-09 S. CICERO AVE.
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2452
Practice Address - Country:US
Practice Address - Phone:708-780-9777
Practice Address - Fax:708-780-9787
Is Sole Proprietor?:No
Enumeration Date:2008-08-03
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.126615208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
367830Medicare PIN