Provider Demographics
NPI:1205846771
Name:HAZLEHURST, THOMAS B (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:B
Last Name:HAZLEHURST
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:39159 PASEO PADRE PKWY
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1608
Mailing Address - Country:US
Mailing Address - Phone:510-505-1091
Mailing Address - Fax:510-505-1111
Practice Address - Street 1:1900 SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2200
Practice Address - Country:US
Practice Address - Phone:650-400-0277
Practice Address - Fax:650-340-1785
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG37365207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
290007636OtherMEDICARE RAILROAD
CAG37365OtherLICENSE
CA00G373651Medicaid
CAA47054Medicare UPIN
CA00G373650Medicare PIN