Provider Demographics
NPI:1154328797
Name:AZAN, ABRAHAM N (MD)
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:N
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 1:601 E 14TH ST
Mailing Address - Street 2:PO BOX 1706
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-5972
Mailing Address - Country:US
Mailing Address - Phone:866-678-5627
Mailing Address - Fax:660-827-3742
Practice Address - Street 1:667 E 15TH ST
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-7656
Practice Address - Country:US
Practice Address - Phone:660-827-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORA490207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO160059401OtherPALMETTO GBA
MO201280427Medicaid
MO08571025OtherBLUE CROSS BLUE SHIELD
MO08571025OtherBLUE CROSS BLUE SHIELD
MO201280427Medicaid