Provider Demographics
NPI:1760542807
Name:BAZAN, JHONNY MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:JHONNY
Middle Name:MARTIN
Last Name:BAZAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3108 LOS MILAGROS
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-7678
Mailing Address - Country:US
Mailing Address - Phone:956-519-9500
Mailing Address - Fax:956-519-9549
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:956-519-9549
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1355208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX041729706Medicaid
TX041729703,Medicaid
TX041729704Medicaid
TX8V4020OtherBLUE CROSS BLUE SHIELD
TX041729705Medicaid
TX041729705Medicaid
TX8E5814Medicare PIN