Provider Demographics
NPI:1417314477
Name:BAZRAFSHAN, SAM (DPM)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:BAZRAFSHAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 CIRCLE 75 PKWY SE
Mailing Address - Street 2:SUITE 900
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3035
Mailing Address - Country:US
Mailing Address - Phone:678-426-2171
Mailing Address - Fax:404-446-1957
Practice Address - Street 1:4308 BRAINERD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411
Practice Address - Country:US
Practice Address - Phone:423-698-1966
Practice Address - Fax:423-697-7207
Is Sole Proprietor?:No
Enumeration Date:2016-01-21
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001307213E00000X
FLPR349213ES0103X
TN790213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ023367Medicaid