Provider Demographics
NPI:1679880058
Name:LYNETTE HAZELBAKER MD PC
Entity Type:Organization
Organization Name:LYNETTE HAZELBAKER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAZELBAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-864-8727
Mailing Address - Street 1:3508 S LAFOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-3803
Mailing Address - Country:US
Mailing Address - Phone:765-864-8727
Mailing Address - Fax:765-453-8638
Practice Address - Street 1:3508 S LAFOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3803
Practice Address - Country:US
Practice Address - Phone:765-864-8727
Practice Address - Fax:765-453-8638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100137490BMedicaid
IN132790Medicare Oscar/Certification