MEDICARE: JOHN LLOYD BEZZANT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	319	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	107006257102	OTHER	UT	IHC

General Provider Information

NPI Number	:	1730175720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN LLOYD BEZZANT M.D.

Provider Business Mailing Address
First Line	:	558 S MURDOCK DR
Second Line	:
City	:	PLEASANT GROVE
State	:	UT
Zip	:	84062-3271
Country	:	US
Telephone Number	:	801-581-6465
Fax Number	:	801-581-6484

Provider Business Practice Location Address
First Line	:	4A330 SCHOOL OF MEDICINE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84132-2409
Country	:	US
Telephone Number	:	801-581-6465
Fax Number	:	801-581-6484

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2005
Last Update Date	:	01/29/2015

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