Provider Demographics
NPI:1205846789
Name:THOMAS B HAZLEHURST, M.D.
Entity Type:Organization
Organization Name:THOMAS B HAZLEHURST, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:B
Authorized Official - Last Name:HAZLEHURST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-400-0277
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37365207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ22064ZMedicare PIN
CAZZZ22064ZMedicare PIN