Provider Demographics
NPI:1063944908
Name:BAZOUN, NASSER VICTOR (DO)
Entity type:Individual
Prefix:
First Name:NASSER
Middle Name:VICTOR
Last Name:BAZOUN
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 DRAWER PH
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503
Mailing Address - Country:US
Mailing Address - Phone:928-674-7001
Mailing Address - Fax:
Practice Address - Street 1:US HWY 191 & HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503
Practice Address - Country:US
Practice Address - Phone:928-674-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5101025501207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program