Provider Demographics
NPI:1952316812
Name:GERARD BAZILE MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:GERARD BAZILE MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:IRVELT
Authorized Official - Last Name:BAZILE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-286-0100
Mailing Address - Street 1:PO BOX 1770
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91944-1770
Mailing Address - Country:US
Mailing Address - Phone:619-464-1165
Mailing Address - Fax:619-567-1011
Practice Address - Street 1:6699 ALVARADO RD
Practice Address - Street 2:SUITE 2306
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5238
Practice Address - Country:US
Practice Address - Phone:619-286-0100
Practice Address - Fax:619-286-0600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW20800Medicare PIN