Healthcare Provider Details

I. General information

NPI: 1063423150
Provider Name (Legal Business Name): STEPHEN J BAZZANO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 7TH ST
GALENA KS
66739-1229
US

IV. Provider business mailing address

PO BOX 277 111 E 7TH ST
GALENA KS
66739
US

V. Phone/Fax

Practice location:
  • Phone: 620-783-1358
  • Fax: 620-783-5055
Mailing address:
  • Phone: 620-783-1358
  • Fax: 620-783-5055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number32305
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14599
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: