Healthcare Provider Details

I. General information

NPI: 1710290713
Provider Name (Legal Business Name): CHARLES PATRICK HAZEN D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2010
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 LOMITA BLVD 2ND FLOOR
HARBOR CITY CA
90710-2076
US

IV. Provider business mailing address

1403 LOMITA BLVD 2ND FLOOR
HARBOR CITY CA
90710-2076
US

V. Phone/Fax

Practice location:
  • Phone: 310-534-6223
  • Fax: 310-326-7205
Mailing address:
  • Phone: 310-534-6223
  • Fax: 310-326-7205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number20A12785
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberOT013853
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: