Provider Demographics
NPI:1710048756
Name:JHONNY MARTIN BAZAN MD PA
Entity Type:Organization
Organization Name:JHONNY MARTIN BAZAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MD
Authorized Official - Prefix:
Authorized Official - First Name:JHONNY
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:BAZAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-519-9500
Mailing Address - Street 1:3108 LOS MILAGROS
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572
Mailing Address - Country:US
Mailing Address - Phone:956-519-9500
Mailing Address - Fax:956-514-9414
Practice Address - Street 1:1337 E PALMAVISTA DR
Practice Address - Street 2:SUITE A
Practice Address - City:PALMVIEW
Practice Address - State:TX
Practice Address - Zip Code:78572
Practice Address - Country:US
Practice Address - Phone:956-519-9500
Practice Address - Fax:956-519-4549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1355208000000X, 208D00000X
TX220041063251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX220041063OtherCASE MANAGEMENT
TX173560701Medicaid
TX0066NLOtherBLUE CROSS BLUE SHIELD
TX1912169459OtherNPI
TX1912169459OtherNPI
G65819Medicare UPIN