Basic Information
| Provider Information | |||||||||
| NPI: | 1043564586 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAZRAT | ||||||||
| FirstName: | EHSAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE | ||||||||
| Address2: | DEPT 358 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986839324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417675200 | ||||||||
| FaxNumber: | 5417675353 | ||||||||
| Practice Location | |||||||||
| Address1: | 1515 VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | COTTAGE GROVE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974249700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417675200 | ||||||||
| FaxNumber: | 5417675353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2012 | ||||||||
| LastUpdateDate: | 03/10/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 125062419 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.