Provider Demographics
NPI:1538139779
Name:HAZEN, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HAZEN
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 601067
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1067
Mailing Address - Country:US
Mailing Address - Phone:704-444-4244
Mailing Address - Fax:704-347-5261
Practice Address - Street 1:2209 S STERLING ST
Practice Address - Street 2:SUITE 600
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-4091
Practice Address - Country:US
Practice Address - Phone:704-444-4244
Practice Address - Fax:704-347-5261
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039253207RC0000X
NC2011-00879207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912675Medicaid
IN100101790Medicaid
IN260690FFOtherMEDICARE
IN000000087407OtherANTHEM
NC1538139779Medicaid
110070255OtherRAILROAD
SCQ0087JMedicaid
INP00783721OtherRAILROAD
OH0822604Medicaid
110070255OtherRAILROAD
IN100101790Medicaid
IN260690FFOtherMEDICARE
INP00783721OtherRAILROAD
OH0822604Medicaid