Healthcare Provider Details

I. General information

NPI: 1861015695
Provider Name (Legal Business Name): MICHAEL OGENE BAZZI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 CAMPUS POINT DR # 7894
LA JOLLA CA
92037-1300
US

IV. Provider business mailing address

9300 CAMPUS POINT DR # 7894
LA JOLLA CA
92037-1300
US

V. Phone/Fax

Practice location:
  • Phone: 619-940-7623
  • Fax:
Mailing address:
  • Phone: 619-940-7623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number20A20371
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: