Provider Demographics
NPI:1679695761
Name:BLEAZARD, SCOTT L (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:L
Last Name:BLEAZARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1086
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-1086
Mailing Address - Country:US
Mailing Address - Phone:530-842-7297
Mailing Address - Fax:530-842-9054
Practice Address - Street 1:914 PINE ST
Practice Address - Street 2:
Practice Address - City:MT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067
Practice Address - Country:US
Practice Address - Phone:530-926-9329
Practice Address - Fax:855-251-4626
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD225032085R0202X
CAC557922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology