Provider Demographics
NPI:1225024573
Name:AZAM, SYED T (MD)
Entity Type:Individual
Prefix:
First Name:SYED
Middle Name:T
Last Name:AZAM
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 1:13180 E COLOSSAL CAVE RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-9794
Mailing Address - Country:US
Mailing Address - Phone:520-762-1557
Mailing Address - Fax:520-762-8019
Practice Address - Street 1:13180 E COLOSSAL CAVE RD
Practice Address - Street 2:SUITE 150
Practice Address - City:VAIL
Practice Address - State:AZ
Practice Address - Zip Code:85641-9794
Practice Address - Country:US
Practice Address - Phone:520-762-1557
Practice Address - Fax:520-762-8019
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31208207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ758683Medicaid
H73634Medicare UPIN
AZ72954Medicare ID - Type Unspecified