Provider Demographics
NPI:1558542688
Name:JOHN L. BEZZANT, M.D. P.C.
Entity Type:Organization
Organization Name:JOHN L. BEZZANT, M.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:BEZZANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-785-7414
Mailing Address - Street 1:PO BOX 830
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-0830
Mailing Address - Country:US
Mailing Address - Phone:801-785-7414
Mailing Address - Fax:
Practice Address - Street 1:84 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-2630
Practice Address - Country:US
Practice Address - Phone:801-785-7414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT162911-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528701330006Medicaid
UT528701330006Medicaid