Healthcare Provider Details

I. General information

NPI: 1124291224
Provider Name (Legal Business Name): SOUMYADIPTA HAZRA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4441 E KINGS CANYON RD
FRESNO CA
93702-3604
US

IV. Provider business mailing address

4441 E KINGS CANYON RD
FRESNO CA
93702-3604
US

V. Phone/Fax

Practice location:
  • Phone: 559-600-4099
  • Fax:
Mailing address:
  • Phone: 559-600-4099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number247252
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA-118104
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: