Provider Demographics
NPI:1669477477
Name:BAHAROZIAN, DWAYNE B (MD)
Entity Type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:B
Last Name:BAHAROZIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CORNERSTONE SQUARE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WESTFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01886-3198
Mailing Address - Country:US
Mailing Address - Phone:978-692-1400
Mailing Address - Fax:
Practice Address - Street 1:5 CORNERSTONE SQUARE
Practice Address - Street 2:SUITE 101
Practice Address - City:WESTFORD
Practice Address - State:MA
Practice Address - Zip Code:01886-3198
Practice Address - Country:US
Practice Address - Phone:978-692-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA71936174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3070379Medicaid
MAJ10428OtherBC/BS MA
MA3070379Medicaid
MAJ10428OtherBC/BS MA
MAJ10428Medicare ID - Type Unspecified