Provider Demographics
NPI:1538691944
Name:HAZLE, MATTHEW SMITH (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:SMITH
Last Name:HAZLE
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 1:1540 E HOSPITAL DR SPC 4280
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-4280
Mailing Address - Country:US
Mailing Address - Phone:734-763-9672
Mailing Address - Fax:
Practice Address - Street 1:1540 E HOSPITAL DR SPC 4280
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-4280
Practice Address - Country:US
Practice Address - Phone:734-763-9672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301506317208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program