Provider Demographics
NPI:1710290713
Name:HAZEN, CHARLES PATRICK (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:PATRICK
Last Name:HAZEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 LOMITA BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-2076
Mailing Address - Country:US
Mailing Address - Phone:310-534-6223
Mailing Address - Fax:310-326-7205
Practice Address - Street 1:1403 LOMITA BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-2076
Practice Address - Country:US
Practice Address - Phone:310-534-6223
Practice Address - Fax:310-326-7205
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-19
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A127852081S0010X
PAOT013853208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine