Provider Demographics
NPI:1417011008
Name:BAZALDUA, GILBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:GILBERT
Middle Name:
Last Name:BAZALDUA
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 328
Mailing Address - Street 2:
Mailing Address - City:WHITE HOUSE
Mailing Address - State:TN
Mailing Address - Zip Code:37188-0328
Mailing Address - Country:US
Mailing Address - Phone:615-672-3767
Mailing Address - Fax:615-672-1118
Practice Address - Street 1:614B HWY 76
Practice Address - Street 2:
Practice Address - City:WHITE HOUSE
Practice Address - State:TN
Practice Address - Zip Code:37188
Practice Address - Country:US
Practice Address - Phone:615-672-3767
Practice Address - Fax:615-672-1118
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD012487174400000X
TNMD12487207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN003132265OtherBLUE CROSS
TN44D0307958OtherCLIA
TN3190469Medicare ID - Type Unspecified
TNB04422Medicare UPIN