Provider Demographics
NPI:1821208794
Name:WILEY, HAZEL (DO)
Entity Type:Individual
Prefix:
First Name:HAZEL
Middle Name:
Last Name:WILEY
Suffix:
Gender:F
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:PO BOX 9834
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33075-0834
Mailing Address - Country:US
Mailing Address - Phone:954-821-0737
Mailing Address - Fax:
Practice Address - Street 1:4900 W OAKLAND PARK BLVD
Practice Address - Street 2:SUITE 309
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-7500
Practice Address - Country:US
Practice Address - Phone:954-821-0737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010165642084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCN002AMedicare PIN