Provider Demographics
NPI:1003843848
Name:AZAN, KENNETH NAJEEB (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:NAJEEB
Last Name:AZAN
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 1:1718 S INGRAM AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-7505
Mailing Address - Country:US
Mailing Address - Phone:660-827-2535
Mailing Address - Fax:660-826-5228
Practice Address - Street 1:1718 S INGRAM AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-7505
Practice Address - Country:US
Practice Address - Phone:660-827-2535
Practice Address - Fax:660-826-5228
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6443207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200112605Medicaid
MO111077637OtherRAILROAD MEDICARE
MO06594013OtherBLUE CROSS BLUE SHIELD KC
MOC50295Medicare UPIN
MO000333101Medicare PIN