Provider Demographics
NPI:1710048756
Name:JHONNY MARTIN BAZAN MD PA
Entity type:Organization
Organization Name:JHONNY MARTIN BAZAN MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER MD/ PROVIDER/ PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JHONNY
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:BAZAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-519-9500
Mailing Address - Street 1:1337 E PALMA VISTA DR STE A
Mailing Address - Street 2:
Mailing Address - City:PALMVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:78572-2055
Mailing Address - Country:US
Mailing Address - Phone:956-519-9500
Mailing Address - Fax:956-514-9414
Practice Address - Street 1:1337 E PALMA VISTA DR STE A
Practice Address - Street 2:
Practice Address - City:PALMVIEW
Practice Address - State:TX
Practice Address - Zip Code:78572-2055
Practice Address - Country:US
Practice Address - Phone:956-519-9500
Practice Address - Fax:956-519-4549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2024-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1355208000000X, 208D00000X
207R00000X
TX220041063251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX041729705Medicaid
TX041729703Medicaid
TX173560701Medicaid
TX220041063OtherCASE MANAGEMENT
TX0066NLOtherBLUE CROSS BLUE SHIELD
TX1912169459OtherNPI