Provider Demographics
NPI:1508843798
Name:MARTIN, AMY HAZELTON (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:HAZELTON
Last Name:MARTIN
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 1:37 DEERFIELD LN
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-2627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 CRANBROOK BLVD
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3889
Practice Address - Country:US
Practice Address - Phone:860-299-3519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-130322085R0202X
CTMD0463452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology