1073714358 NPI number — HERNAN ANTONIO BAZAN M.D.

Table of content: HERNAN ANTONIO BAZAN M.D. (NPI 1073714358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073714358 NPI number — HERNAN ANTONIO BAZAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAZAN
Provider First Name:
HERNAN
Provider Middle Name:
ANTONIO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073714358
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1514 JEFFERSON HIGHWAY
Provider Second Line Business Mailing Address:
8TH FLOOR-CLINIC
Provider Business Mailing Address City Name:
NEW ORLEANS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-842-4053
Provider Business Mailing Address Fax Number:
504-842-5017

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1514 JEFFERSON HIGHWAY
Provider Second Line Business Practice Location Address:
8TH FLOOR-CLINIC
Provider Business Practice Location Address City Name:
NEW ORLEANS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
07012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-842-4053
Provider Business Practice Location Address Fax Number:
504-842-5017
Provider Enumeration Date:
05/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  044485 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X , with the licence number: 201525 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 044485 . This is a "LICENSE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 01078003 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1014630 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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