Provider Demographics
NPI:1790715647
Name:HAZLETT, HOLLY H (MD)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:H
Last Name:HAZLETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:H
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9303 PINECROFT DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-3180
Mailing Address - Country:US
Mailing Address - Phone:281-363-5050
Mailing Address - Fax:281-363-5020
Practice Address - Street 1:9303 PINECROFT DR
Practice Address - Street 2:SUITE 150
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-3180
Practice Address - Country:US
Practice Address - Phone:281-363-5050
Practice Address - Fax:281-363-5020
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8491207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
5600638OtherAETNA
TX8J5520OtherBLUE CROSS BLUE SHIELD
P00098339OtherRAILROAD MEDICARE
G40179Medicare UPIN
8A7260Medicare PIN