Provider Demographics
NPI:1780683037
Name:HAZLETT, SAMUEL M (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:M
Last Name:HAZLETT
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 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N RITTER AVE
Practice Address - Street 2:SUITE 520
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3052
Practice Address - Country:US
Practice Address - Phone:317-355-1234
Practice Address - Fax:317-355-1505
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028492A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01191752OtherRR MEDICARE PTAN
IN100260540BMedicaid
IN266180107Medicare PIN
IN251320LLMedicare PIN
IN248520IMedicare PIN
INP01191752OtherRR MEDICARE PTAN
IND94587Medicare UPIN
IN100260540BMedicaid