Provider Demographics
NPI:1407018187
Name:BAZANT, MARK PAUL (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:PAUL
Last Name:BAZANT
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3991 DUTCHMANS LN
Practice Address - Street 2:SUITE 310
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4700
Practice Address - Country:US
Practice Address - Phone:502-899-6782
Practice Address - Fax:502-899-6783
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01071068A2084N0400X
KY458242084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000824411OtherANTHEM
KY7100245160Medicaid
KY7100245160Medicaid