Healthcare Provider Details

I. General information

NPI: 1649587676
Provider Name (Legal Business Name): OMID HAZINI DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2010
Last Update Date: 09/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO S.E.
ALBUQUERQUE NM
87108
US

IV. Provider business mailing address

8001 OSO LOCO DR NE
ALBUQUERQUE NM
87122-1376
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberT1030
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: