Healthcare Provider Details

I. General information

NPI: 1558849034
Provider Name (Legal Business Name): GREGORY MAURICE BAZEMORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3504 LESLIE AVE
TEMPLE HILLS MD
20748-4634
US

IV. Provider business mailing address

3504 LESLIE AVE
TEMPLE HILLS MD
20748-4634
US

V. Phone/Fax

Practice location:
  • Phone: 703-955-2567
  • Fax:
Mailing address:
  • Phone: 703-955-2567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number04-110002
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: