Provider Demographics
NPI:1679204713
Name:BAZANTE, JORGE
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:BAZANTE
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 1:100 KINGS POINT DR APT 1510
Mailing Address - Street 2:
Mailing Address - City:SUNNY ISLES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-4730
Mailing Address - Country:US
Mailing Address - Phone:561-900-6650
Mailing Address - Fax:
Practice Address - Street 1:53 ASH DR
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33026-1102
Practice Address - Country:US
Practice Address - Phone:561-767-4421
Practice Address - Fax:561-768-7269
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL32002225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty