Provider Demographics
NPI:1730634965
Name:DESERT SPURS PRIMARY CARE, PLLC
Entity Type:Organization
Organization Name:DESERT SPURS PRIMARY CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAZACO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-464-8311
Mailing Address - Street 1:251 MOSER AVE
Mailing Address - Street 2:APT. 105
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86429-5240
Mailing Address - Country:US
Mailing Address - Phone:210-464-8311
Mailing Address - Fax:
Practice Address - Street 1:1355 RAMAR RD
Practice Address - Street 2:STE. 10
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7100
Practice Address - Country:US
Practice Address - Phone:928-444-8405
Practice Address - Fax:928-299-5300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ48283207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP20970983OtherCORPORATION ID#