MEDICARE: BANZI L. BAZAZ M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	108852	NY

General Provider Information

NPI Number	:	1780681056
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BANZI L. BAZAZ M.D.

Provider Business Mailing Address
First Line	:	3 LYON PLACE
Second Line	:
City	:	OGDENSBURG
State	:	NY
Zip	:	13669
Country	:	US
Telephone Number	:	315-394-7542
Fax Number	:	315-394-0015

Provider Business Practice Location Address
First Line	:	3 LYON PLACE
Second Line	:	STE. 102
City	:	OGDENSBURG
State	:	NY
Zip	:	13669
Country	:	US
Telephone Number	:	315-394-6473
Fax Number	:	315-394-8810

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	08/05/2010

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