Healthcare Provider Details

I. General information

NPI: 1437520061
Provider Name (Legal Business Name): DANIEL ADRIAN BAZUA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2015
Last Update Date: 07/01/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
TACOMA WA
98431-0001
US

IV. Provider business mailing address

9040 JACKSON AVE
TACOMA WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-0198
  • Fax:
Mailing address:
  • Phone: 253-968-2252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number9560001-9934
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: