Provider Demographics
NPI:1073583886
Name:AZEVEDO, MICHAEL P (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:AZEVEDO
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 1:1805 E FIR AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3859
Mailing Address - Country:US
Mailing Address - Phone:559-325-3070
Mailing Address - Fax:559-325-3073
Practice Address - Street 1:1805 E FIR AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3859
Practice Address - Country:US
Practice Address - Phone:559-325-3070
Practice Address - Fax:559-325-3073
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66383208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A663830Medicaid
320024715OtherBLUE CROSS
00A663830OtherBLUE SHIELD
348538500OtherUS DEPT OF LABOR
00A663830OtherBLUE SHIELD
H21959Medicare UPIN