Basic Information
| Provider Information | |||||||||
| NPI: | 1851495337 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAZZOUI | ||||||||
| FirstName: | WIDAD | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 565 MINARD RUN RD | ||||||||
| Address2: | |||||||||
| City: | BRADFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 167013764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143626535 | ||||||||
| FaxNumber: | 8143627358 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 CAMPUS DR | ||||||||
| Address2: | |||||||||
| City: | BRADFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 167011982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143626535 | ||||||||
| FaxNumber: | 8143627358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 174400000X | MD034596L | PA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 000547864 | 05 | PA | MEDICAID |