Provider Demographics
NPI:1841207974
Name:BAZA, MARVIN L JR (OD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:L
Last Name:BAZA
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8020
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77508-8020
Mailing Address - Country:US
Mailing Address - Phone:281-998-2020
Mailing Address - Fax:281-998-2246
Practice Address - Street 1:4415 CRENSHAW RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504-3628
Practice Address - Country:US
Practice Address - Phone:281-998-2020
Practice Address - Fax:281-998-2246
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02280TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX410018532Medicare PIN
TXT12125Medicare UPIN
TX0490720001Medicare NSC