Provider Demographics
NPI:1689028243
Name:MATHES, HAZEL A (DO)
Entity Type:Individual
Prefix:
First Name:HAZEL
Middle Name:A
Last Name:MATHES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:HAZEL
Other - Middle Name:A
Other - Last Name:DEHUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:744 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3505
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-3655
Practice Address - Fax:920-433-3539
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69715-21208100000X
WI6606-851208100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program