Provider Demographics
NPI:1639229271
Name:BAZARTE, JOSEPH M (OD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:M
Last Name:BAZARTE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 LISENBY AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-3711
Mailing Address - Country:US
Mailing Address - Phone:850-913-0000
Mailing Address - Fax:850-785-1988
Practice Address - Street 1:1611 LISENBY AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-3711
Practice Address - Country:US
Practice Address - Phone:850-913-0000
Practice Address - Fax:850-785-1988
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC001596152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620189000Medicaid
FL620189000Medicaid
FL0877480001Medicare NSC
FL19809AMedicare ID - Type Unspecified
FL620189000Medicaid