Provider Demographics
NPI:1972604650
Name:BAZZONE, VICTOR T (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:T
Last Name:BAZZONE
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 1:15190 COMMUNITY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3485
Mailing Address - Country:US
Mailing Address - Phone:228-831-2229
Mailing Address - Fax:228-539-8313
Practice Address - Street 1:15190 COMMUNITY RD
Practice Address - Street 2:SUITE 300
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3485
Practice Address - Country:US
Practice Address - Phone:228-831-2229
Practice Address - Fax:228-539-8313
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07091174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00304930OtherRAILROAD MEDICARE
MS078783859Medicaid
MS078783859Medicaid
MS078783859Medicaid