Healthcare Provider Details

I. General information

NPI: 1033190202
Provider Name (Legal Business Name): SHANE M BEZZANT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W THOMAS RD
PHOENIX AZ
85013-4409
US

IV. Provider business mailing address

PO BOX 33269
PHOENIX AZ
85067-3269
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-3430
  • Fax: 602-406-2340
Mailing address:
  • Phone: 602-406-4786
  • Fax: 916-636-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number01058636A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number50862
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: