Provider Demographics
NPI:1861502403
Name:HAZZARD, ROOSEVELT (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROOSEVELT
Middle Name:
Last Name:HAZZARD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22102 100TH DR
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-1638
Mailing Address - Country:US
Mailing Address - Phone:718-217-3762
Mailing Address - Fax:
Practice Address - Street 1:9703 SPRINGFIELD BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-1328
Practice Address - Country:US
Practice Address - Phone:718-465-7200
Practice Address - Fax:718-465-0407
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005145213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01578830Medicaid
NYU51385Medicare UPIN
NY01578830Medicaid