Provider Demographics
NPI:1073714358
Name:BAZAN, HERNAN ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:HERNAN
Middle Name:ANTONIO
Last Name:BAZAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HIGHWAY
Mailing Address - Street 2:8TH FLOOR-CLINIC
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121
Mailing Address - Country:US
Mailing Address - Phone:504-842-4053
Mailing Address - Fax:504-842-5017
Practice Address - Street 1:1514 JEFFERSON HIGHWAY
Practice Address - Street 2:8TH FLOOR-CLINIC
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:07012
Practice Address - Country:US
Practice Address - Phone:504-842-4053
Practice Address - Fax:504-842-5017
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0444852086S0129X
LA2015252086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT044485OtherLICENSE
MS01078003Medicaid
LA1014630Medicaid
LA1014630Medicaid
CT044485OtherLICENSE
MS01078003Medicaid
LA4K670F669Medicare PIN