Provider Demographics
NPI:1043218472
Name:HAZLEWOOD, MICHAEL GERARD (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GERARD
Last Name:HAZLEWOOD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 356
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72115-0356
Mailing Address - Country:US
Mailing Address - Phone:501-224-9876
Mailing Address - Fax:
Practice Address - Street 1:60 WOODLORE CIR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-2354
Practice Address - Country:US
Practice Address - Phone:501-224-9876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR 79-32P103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5-6189Medicare ID - Type Unspecified