Healthcare Provider Details

I. General information

NPI: 1366603060
Provider Name (Legal Business Name): SHARAREH HAZINI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 06/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110-7613
US

IV. Provider business mailing address

8300 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110-7613
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-2402
  • Fax:
Mailing address:
  • Phone: 505-291-2402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2012-0004
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: