Provider Demographics
NPI:1104135128
Name:BAUZA-FELICIANO, PEDRO A (MD)
Entity type:Individual
Prefix:
First Name:PEDRO
Middle Name:A
Last Name:BAUZA-FELICIANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PEDRO
Other - Middle Name:A
Other - Last Name:BAUZA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:2000 BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4627
Practice Address - Country:US
Practice Address - Phone:423-857-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-26
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCDR.00044652084P0800X
VA01012803942084P0800X
MI43011047292084P0800X
PAMD4476312084P0800X
TN692242084P0800X
OH351338312084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232359401OtherMLHC TAX ID