Provider Demographics
NPI:1912968504
Name:HAZEL, HEATHER STEPHANIE (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:STEPHANIE
Last Name:HAZEL
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 1:650 DICKINSON RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-3387
Mailing Address - Country:US
Mailing Address - Phone:219-926-2133
Mailing Address - Fax:
Practice Address - Street 1:650 DICKINSON RD
Practice Address - Street 2:SUITE A
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-3387
Practice Address - Country:US
Practice Address - Phone:219-926-2133
Practice Address - Fax:219-926-8765
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060598A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200529530BMedicaid
5251392OtherAETNA
000000521727OtherANTHEM
5251392OtherAETNA
IN252000HMedicare PIN