Healthcare Provider Details

I. General information

NPI: 1679005078
Provider Name (Legal Business Name): JULIAN MICHAEL HAZELTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 06/16/2024
Certification Date: 06/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 OAKWOOD BLVD
DEARBORN MI
48124-2319
US

IV. Provider business mailing address

840 OAKWOOD BLVD
DEARBORN MI
48124-2319
US

V. Phone/Fax

Practice location:
  • Phone: 313-359-7600
  • Fax: 313-359-7678
Mailing address:
  • Phone: 313-359-7600
  • Fax: 313-359-7678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number4301509486
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: