Provider Demographics
NPI:1063423150
Name:BAZZANO, STEPHEN J (DO)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:BAZZANO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:111 E 7TH ST
Mailing Address - City:GALENA
Mailing Address - State:KS
Mailing Address - Zip Code:66739
Mailing Address - Country:US
Mailing Address - Phone:620-783-1358
Mailing Address - Fax:620-783-5055
Practice Address - Street 1:111 E 7TH ST
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:KS
Practice Address - Zip Code:66739-1229
Practice Address - Country:US
Practice Address - Phone:620-783-1358
Practice Address - Fax:620-783-5055
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO32305207Q00000X
KS14599207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100098210AMedicaid
MO240387613Medicaid
KS080075003OtherPALMETTO GBA RAILROAD MCR
KS080075003OtherPALMETTO GBA RAILROAD MCR
MO240387613Medicaid
080075003Medicare PIN
KS009519Medicare PIN
KS100098210AMedicaid
MOD41501Medicare UPIN