Healthcare Provider Details

I. General information

NPI: 1750361259
Provider Name (Legal Business Name): MARK B HAZUKA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 N NEVADA AVE STE CC101
COLORADO SPRINGS CO
80907
US

IV. Provider business mailing address

PO BOX 800022
KANSAS CITY MO
64180-0022
US

V. Phone/Fax

Practice location:
  • Phone: 719-776-5281
  • Fax: 719-776-2525
Mailing address:
  • Phone: 800-953-0104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberMC-0086
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number14214
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number26111
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberMD2014-0165
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: