Provider Demographics
NPI:1689643496
Name:BAZO, CHARBAL B (MD)
Entity Type:Individual
Prefix:
First Name:CHARBAL
Middle Name:B
Last Name:BAZO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1641 10TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-5844
Mailing Address - Country:US
Mailing Address - Phone:810-987-7200
Mailing Address - Fax:810-987-5396
Practice Address - Street 1:1641 10TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5844
Practice Address - Country:US
Practice Address - Phone:810-987-7200
Practice Address - Fax:810-987-5396
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2010-12-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301058428207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1689643496Medicaid
F88990Medicare UPIN