Provider Demographics
NPI:1780681056
Name:BAZAZ, BANZI L (MD)
Entity Type:Individual
Prefix:
First Name:BANZI
Middle Name:L
Last Name:BAZAZ
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 1:3 LYON PLACE
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669
Mailing Address - Country:US
Mailing Address - Phone:315-394-7542
Mailing Address - Fax:315-394-0015
Practice Address - Street 1:3 LYON PLACE
Practice Address - Street 2:STE. 102
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669
Practice Address - Country:US
Practice Address - Phone:315-394-6473
Practice Address - Fax:315-394-8810
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108852207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
34750BMedicare ID - Type Unspecified
B82581Medicare UPIN
J400011285Medicare PIN