Provider Demographics
NPI:1447250329
Name:KAZA, BASAVAPUNNA R (MD)
Entity type:Individual
Prefix:
First Name:BASAVAPUNNA
Middle Name:R
Last Name:KAZA
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:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:SPRINGHILL
Mailing Address - State:LA
Mailing Address - Zip Code:71075-0158
Mailing Address - Country:US
Mailing Address - Phone:318-539-3809
Mailing Address - Fax:
Practice Address - Street 1:1100 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:SPRINGHILL
Practice Address - State:LA
Practice Address - Zip Code:71075-4528
Practice Address - Country:US
Practice Address - Phone:318-539-3809
Practice Address - Fax:318-539-4189
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10941R2084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR156295001Medicaid
LA1548596Medicaid
LA1548596Medicaid
AR156295001Medicaid