Healthcare Provider Details

I. General information

NPI: 1023025632
Provider Name (Legal Business Name): R MARK HAZEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 01/14/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 JESSE JEWELL PKWY NE STE 300
GAINESVILLE GA
30501
US

IV. Provider business mailing address

10600 MEDLOCK BRIDGE RD
DULUTH GA
30097-8404
US

V. Phone/Fax

Practice location:
  • Phone: 770-848-6190
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD47860
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number073631
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: