Provider Demographics
NPI:1861840803
Name:BAZA, JONATHAN (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:BAZA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W 27TH ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3075
Mailing Address - Country:US
Mailing Address - Phone:910-738-2662
Mailing Address - Fax:910-272-7153
Practice Address - Street 1:300 W 27TH ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3075
Practice Address - Country:US
Practice Address - Phone:910-738-2662
Practice Address - Fax:910-272-7153
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC219504207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine