Provider Demographics
NPI:1649769985
Name:BAZA, LOREN (OD)
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:
Last Name:BAZA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1649 SANDLE WOOD DR
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76087-1235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6014 AZLE AVE STE 200
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-2603
Practice Address - Country:US
Practice Address - Phone:682-312-2603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9179T152W00000X
TX9179TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist