Provider Demographics
NPI:1366471161
Name:TEJANO, HAZEL CARVAJAL (RPT)
Entity Type:Individual
Prefix:MS
First Name:HAZEL
Middle Name:CARVAJAL
Last Name:TEJANO
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5899 WHITFIELD AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-6152
Mailing Address - Country:US
Mailing Address - Phone:941-359-2977
Mailing Address - Fax:941-359-2966
Practice Address - Street 1:5664 BEE RIDGE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-1504
Practice Address - Country:US
Practice Address - Phone:941-343-9291
Practice Address - Fax:941-343-9568
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21897225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU4636ZMedicare ID - Type UnspecifiedMCB