Healthcare Provider Details

I. General information

NPI: 1689829384
Provider Name (Legal Business Name): JOHN SAMPSON BLEAZARD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2008
Last Update Date: 07/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 NALL AVE STE 200
OVERLAND PARK KS
66211-1358
US

IV. Provider business mailing address

12639 OLD TESSON RD STE 100
SAINT LOUIS MO
63128-2786
US

V. Phone/Fax

Practice location:
  • Phone: 913-381-5225
  • Fax: 913-901-0186
Mailing address:
  • Phone: 913-381-5225
  • Fax: 913-901-0186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2008018690
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: