Provider Demographics
NPI:1003256975
Name:AZIZ, IMAD M (MD)
Entity Type:Individual
Prefix:
First Name:IMAD
Middle Name:M
Last Name:AZIZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1844
Mailing Address - Country:US
Mailing Address - Phone:608-363-5500
Mailing Address - Fax:608-363-5539
Practice Address - Street 1:2825 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1844
Practice Address - Country:US
Practice Address - Phone:608-363-5500
Practice Address - Fax:608-363-5539
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI66349-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1003256975Medicaid
WIK400336425Medicare PIN