1285408138 NPI number — MR. PATRON NKURUNZIZA BAZOZA MD

Table of content: MR. PATRON NKURUNZIZA BAZOZA MD (NPI 1285408138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285408138 NPI number — MR. PATRON NKURUNZIZA BAZOZA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAZOZA
Provider First Name:
PATRON
Provider Middle Name:
NKURUNZIZA
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BAZOZA
Provider Other First Name:
GEDEON
Provider Other Middle Name:
NGABIRE
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1285408138
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
586 WESTBROOK ST UNIT 407
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04106-1405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-518-5324
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
586 WESTBROOK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04106-1400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-518-5324
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/10/2023

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: 103TM1800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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