Healthcare Provider Details

I. General information

NPI: 1710048756
Provider Name (Legal Business Name): JHONNY MARTIN BAZAN MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 10/19/2024
Certification Date: 10/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 E PALMA VISTA DR STE A
PALMVIEW TX
78572-2055
US

IV. Provider business mailing address

1337 E PALMA VISTA DR STE A
PALMVIEW TX
78572-2055
US

V. Phone/Fax

Practice location:
  • Phone: 956-519-9500
  • Fax: 956-519-4549
Mailing address:
  • Phone: 956-519-9500
  • Fax: 956-514-9414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberK1355
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberK1355
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JHONNY MARTIN BAZAN
Title or Position: OWNER MD/ PROVIDER/ PRESIDENT
Credential: MD
Phone: 956-519-9500