Provider Demographics
NPI:1861555245
Name:BAZARKO, TETIANA KIHICZAK (DPM)
Entity type:Individual
Prefix:
First Name:TETIANA
Middle Name:KIHICZAK
Last Name:BAZARKO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:TETIANA
Other - Middle Name:KIHICZAK
Other - Last Name:BAZARKO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:389 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:389 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3444
Practice Address - Country:US
Practice Address - Phone:203-754-0879
Practice Address - Fax:203-757-4123
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000914213E00000X, 213EP1101X
NJ25MD00271900213E00000X, 213EP1101X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery