Provider Demographics
NPI:1235134222
Name:HAZELBAKER, MATTHEW T (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:T
Last Name:HAZELBAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MATTHEW
Other - Middle Name:T
Other - Last Name:HAZELBAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:150 MOREY DR
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-1646
Mailing Address - Country:US
Mailing Address - Phone:937-644-2541
Mailing Address - Fax:937-642-7535
Practice Address - Street 1:150 MOREY DR
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-1646
Practice Address - Country:US
Practice Address - Phone:937-644-2541
Practice Address - Fax:937-642-7535
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35072181174400000X, 207V00000X
OH3507-2181H174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2121484Medicaid
OHHA0883201Medicare ID - Type Unspecified
OH2121484Medicaid