Provider Demographics
NPI:1487660171
Name:HAZELTON, TODD (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:HAZELTON
Suffix:
Gender:M
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:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 MANNING DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-4220
Practice Address - Country:US
Practice Address - Phone:984-974-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME700462085R0202X
NC2022-011372085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253763000Medicaid
FL42740OtherBLUE CROSS BLUE SHIELD
FL42740OtherBLUE CROSS BLUE SHIELD
FL42740OtherBLUE CROSS BLUE SHIELD
FL42740WMedicare PIN
FLP00637962Medicare PIN
FL118719Medicaid
FL300084191Medicare PIN
FL42740XMedicare PIN
FL42740Medicare PIN