Provider Demographics
NPI:1487931770
Name:BAZACO, ROBERT JR (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:BAZACO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2400 HIGHWAY 95 STE 50
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7313
Mailing Address - Country:US
Mailing Address - Phone:928-444-8405
Mailing Address - Fax:928-299-5300
Practice Address - Street 1:2500 CANYON RD STE A1
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-8492
Practice Address - Country:US
Practice Address - Phone:928-704-4499
Practice Address - Fax:928-704-4949
Is Sole Proprietor?:No
Enumeration Date:2011-11-15
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ48283207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ879064Medicaid
AZ3120998OtherCIGNA
AZ7387955OtherAETNA