Provider Demographics
NPI:1851549901
Name:HAZELWOOD, KYLE J (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:J
Last Name:HAZELWOOD
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 1:2500 W A ST STE 201
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-6000
Mailing Address - Country:US
Mailing Address - Phone:208-883-2828
Mailing Address - Fax:208-882-2179
Practice Address - Street 1:2500 W A ST STE 201
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-6000
Practice Address - Country:US
Practice Address - Phone:208-883-2828
Practice Address - Fax:208-882-2179
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ46201207X00000X
IL125052518207X00000X
CA111422207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery