Provider Demographics
NPI:1841211570
Name:HAZELBAKER, LYNETTE (MD)
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:
Last Name:HAZELBAKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3508 S LAFOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-3803
Mailing Address - Country:US
Mailing Address - Phone:765-864-8727
Mailing Address - Fax:765-864-8715
Practice Address - Street 1:3508 S LAFOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3803
Practice Address - Country:US
Practice Address - Phone:765-864-8727
Practice Address - Fax:765-864-8715
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030216207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100137490BMedicaid
IN100137490BMedicaid
132790Medicare ID - Type Unspecified