Provider Demographics
NPI:1538688148
Name:BAZAROV, KONSTANTIN V
Entity Type:Individual
Prefix:
First Name:KONSTANTIN
Middle Name:V
Last Name:BAZAROV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-1208
Mailing Address - Country:US
Mailing Address - Phone:781-856-2747
Mailing Address - Fax:781-856-2747
Practice Address - Street 1:244 CONCORD RD
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MA
Practice Address - Zip Code:01778
Practice Address - Country:US
Practice Address - Phone:781-856-2747
Practice Address - Fax:781-856-2747
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPENDING171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty