Provider Demographics
NPI:1932201837
Name:THEOBALD-HAZEL, KRISTEN ANNE (DO)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ANNE
Last Name:THEOBALD-HAZEL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3050
Mailing Address - Country:US
Mailing Address - Phone:573-302-3100
Mailing Address - Fax:573-348-8279
Practice Address - Street 1:1057 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3000
Practice Address - Country:US
Practice Address - Phone:573-302-3100
Practice Address - Fax:573-348-8279
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009001633208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1447229489Medicaid