Basic Information
| Provider Information | |||||||||
| NPI: | 1982719514 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAZLEY | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1290 GOLFVIEW AVE | ||||||||
| Address2: | ATTN: BILLING DEPARTMENT | ||||||||
| City: | BARTOW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338306740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635197900 | ||||||||
| FaxNumber: | 8635197696 | ||||||||
| Practice Location | |||||||||
| Address1: | 3241 LAKELAND HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338052266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634132620 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 06/23/2016 | ||||||||
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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 | 207V00000X | 36355 | MO | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | ME45747 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 203990411 | 05 | MO | MEDICAID | 119334 | 01 | BLUE CROSS | OTHER | 000046600 | 05 | FL | MEDICAID | 68594 | 01 | FL | BCBS | OTHER | 160048858 | 01 | RAILROAD | OTHER |