Provider Demographics
NPI:1558849034
Name:BAZEMORE, GREGORY MAURICE
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:MAURICE
Last Name:BAZEMORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3504 LESLIE AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-4634
Mailing Address - Country:US
Mailing Address - Phone:703-955-2567
Mailing Address - Fax:
Practice Address - Street 1:3504 LESLIE AVE
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-4634
Practice Address - Country:US
Practice Address - Phone:703-955-2567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD83-1473231OtherHAIR LOSS PRACTITIONER
MD83-1473231Medicaid