Provider Demographics
NPI:1871558767
Name:HAZELBAKER, ROGER DALE (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:DALE
Last Name:HAZELBAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 49 STREET NORTH
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709
Mailing Address - Country:US
Mailing Address - Phone:727-522-0558
Mailing Address - Fax:727-521-3605
Practice Address - Street 1:1417 S BELCHER RD
Practice Address - Street 2:#C
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764
Practice Address - Country:US
Practice Address - Phone:727-535-0741
Practice Address - Fax:757-531-8171
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME41254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A80077Medicare UPIN
02486ZMedicare ID - Type Unspecified