Provider Demographics
NPI:1891863320
Name:BAZAN, LUISA FERNANDA (MD)
Entity Type:Individual
Prefix:
First Name:LUISA
Middle Name:FERNANDA
Last Name:BAZAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2799 WEST GRAND BOULEVARD
Mailing Address - Street 2:HENRY FORD HEALTH SYSTEM
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-916-2421
Mailing Address - Fax:313-916-9102
Practice Address - Street 1:2799 WEST GRAND BOULEVARD
Practice Address - Street 2:HENRY FORD HEALTH SYSTEM
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-916-2421
Practice Address - Fax:313-916-9102
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073791207R00000X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LB073791OtherCOMMERCIAL-COMMERCIAL NUMBER
MI481026010Medicaid
LB073791OtherCHAMPUS-CHAMPUS
700H262220OtherBLUE CROSS-BLUE CROSS
I47558Medicare UPIN
MI481026010Medicaid