Provider Demographics
NPI:1740709807
Name:BAZZONI, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BAZZONI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MANCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46962-1857
Mailing Address - Country:US
Mailing Address - Phone:260-982-1985
Mailing Address - Fax:260-982-1994
Practice Address - Street 1:605 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:NORTH MANCHESTER
Practice Address - State:IN
Practice Address - Zip Code:46962-1857
Practice Address - Country:US
Practice Address - Phone:260-982-1985
Practice Address - Fax:260-982-1994
Is Sole Proprietor?:No
Enumeration Date:2017-09-10
Last Update Date:2017-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006511A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist