Basic Information
| Provider Information | |||||||||
| NPI: | 1063430239 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAZARIAN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 655C | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853413015 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4901 LAC DE VILLE BLVD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146185647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852753271 | ||||||||
| FaxNumber: | 5854422949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 03/26/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 176211 | NY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 176211 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208100000X | 176211 | NY | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 01720850 | 05 | NY | MEDICAID |