Provider Demographics
NPI:1396766994
Name:MCKILLOP, HAZEL (MD)
Entity type:Individual
Prefix:
First Name:HAZEL
Middle Name:
Last Name:MCKILLOP
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:P.O. BOX 2199
Mailing Address - Street 2:1455 W REDONDO BLVD
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247
Mailing Address - Country:US
Mailing Address - Phone:310-370-5888
Mailing Address - Fax:
Practice Address - Street 1:12900 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90061-2734
Practice Address - Country:US
Practice Address - Phone:310-370-5888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50837207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A508371Medicaid
CAG30207Medicare UPIN
CAW18620Medicare ID - Type Unspecified