Healthcare Provider Details

I. General information

NPI: 1871558767
Provider Name (Legal Business Name): ROGER DALE HAZELBAKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1417 S BELCHER RD #C
CLEARWATER FL
33764
US

IV. Provider business mailing address

5767 49 STREET NORTH
ST PETERSBURG FL
33709
US

V. Phone/Fax

Practice location:
  • Phone: 727-535-0741
  • Fax: 757-531-8171
Mailing address:
  • Phone: 727-522-0558
  • Fax: 727-521-3605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME41254
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: