=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588641880
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LETITIA MARIE HAZEL MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2005
-----------------------------------------------------
Last Update Date | 12/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2101 GARNER RD
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27610-0114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-787-6131
-----------------------------------------------------
Fax | 919-571-2932
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 696
-----------------------------------------------------
City | HAMPSTEAD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-791-6767
-----------------------------------------------------
Fax | 910-791-8890
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 200101342
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 200101342
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------