Provider Demographics
NPI:1730274929
Name:TZANETOS, DOUGLAS BAZIL (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:BAZIL
Last Name:TZANETOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9800 SHELBYVILLE RD STE 220
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-2992
Mailing Address - Country:US
Mailing Address - Phone:502-429-8585
Mailing Address - Fax:502-429-6157
Practice Address - Street 1:9113 LEESGATE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5003
Practice Address - Country:US
Practice Address - Phone:502-426-1621
Practice Address - Fax:502-426-7906
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39285207K00000X, 208000000X, 207KA0200X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
207K00000XOtherTAXONOMY
39285OtherKENTUCKY LICENSE
KY64125701Medicaid
KY39285OtherKENTUCKY LICENSE
KY1275309Medicare PIN