Provider Demographics
NPI:1376592071
Name:KHAWAJA, AZIMUDDIN TAREQ (MD)
Entity Type:Individual
Prefix:DR
First Name:AZIMUDDIN
Middle Name:TAREQ
Last Name:KHAWAJA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:A
Other - Middle Name:TAREQ
Other - Last Name:KHAWAJA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:13460 N 94TH DR STE J1
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4246
Mailing Address - Country:US
Mailing Address - Phone:623-876-8816
Mailing Address - Fax:623-298-0168
Practice Address - Street 1:13460 N 94TH DR STE J1
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4246
Practice Address - Country:US
Practice Address - Phone:623-876-8816
Practice Address - Fax:623-298-0168
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33750207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ201349OtherMEDICARE PIN - CARDIAC SOLUTIONS
AZ956758Medicaid
AZG55748Medicare UPIN
AZ956758Medicaid
AZZ201349OtherMEDICARE PIN - CARDIAC SOLUTIONS
AZZ102889Medicare PIN