Provider Demographics
NPI:1215013446
Name:HAZAN, LYDIE (MD)
Entity Type:Individual
Prefix:
First Name:LYDIE
Middle Name:
Last Name:HAZAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8500 WILSHIRE BLVD
Mailing Address - Street 2:#700
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211
Mailing Address - Country:US
Mailing Address - Phone:310-289-8242
Mailing Address - Fax:310-289-8248
Practice Address - Street 1:8500 WILSHIRE BLVD
Practice Address - Street 2:#700
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211
Practice Address - Country:US
Practice Address - Phone:310-289-8242
Practice Address - Fax:310-289-8248
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53116133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA53116Medicare ID - Type Unspecified