Provider Demographics
NPI:1801936638
Name:HAZELWOOD UGARTE, JENNIFER A (OD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:A
Last Name:HAZELWOOD UGARTE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:HAZELWOOD UGARTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:3612 RIDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-3124
Mailing Address - Country:US
Mailing Address - Phone:330-668-0150
Mailing Address - Fax:
Practice Address - Street 1:3612 RIDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-3124
Practice Address - Country:US
Practice Address - Phone:330-668-0150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5764152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHHA4248371Medicare PIN