Provider Demographics
NPI:1487344875
Name:DEREK BAZEMORE MD INC
Entity type:Organization
Organization Name:DEREK BAZEMORE MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:BAZEMORE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:917-750-5709
Mailing Address - Street 1:55 SW 9TH ST APT 1405
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-3992
Mailing Address - Country:US
Mailing Address - Phone:917-750-5709
Mailing Address - Fax:
Practice Address - Street 1:55 SW 9TH ST APT 1405
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33130-3992
Practice Address - Country:US
Practice Address - Phone:917-750-5709
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty