Provider Demographics
NPI:1558591891
Name:HAZEN, BRENT PHILIP (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:PHILIP
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 2699
Mailing Address - Street 2:ATTN: SHMG/HPE
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-416-7619
Mailing Address - Fax:850-416-7753
Practice Address - Street 1:4451 BAYOU BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2601
Practice Address - Country:US
Practice Address - Phone:850-416-7619
Practice Address - Fax:850-416-7753
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-21
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT196193207Q00000X
OH57.017460207R00000X
FLME114426207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14PV8OtherBCBS
FL0095096-00Medicaid