Provider Demographics
NPI:1063407872
Name:BAZARAA, HESHAM M (MD)
Entity type:Individual
Prefix:
First Name:HESHAM
Middle Name:M
Last Name:BAZARAA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:761 45TH ST STE 110
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2899
Practice Address - Country:US
Practice Address - Phone:219-922-3020
Practice Address - Fax:219-922-3023
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01054298A207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200340980Medicaid
IN200340980AMedicaid
IN200340980AMedicaid