Provider Demographics
NPI:1831106103
Name:HAZELBAKER, PAUL NOLAN (DO)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:NOLAN
Last Name:HAZELBAKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-515-2300
Mailing Address - Fax:619-906-4564
Practice Address - Street 1:1250 6TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-4300
Practice Address - Country:US
Practice Address - Phone:619-515-2430
Practice Address - Fax:619-578-2410
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7147207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH24439Medicare UPIN