Provider Demographics
NPI:1407893472
Name:AZEVEDO, ESTEBAN (PT)
Entity Type:Individual
Prefix:
First Name:ESTEBAN
Middle Name:
Last Name:AZEVEDO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 NW BARRY RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64155-2740
Mailing Address - Country:US
Mailing Address - Phone:816-468-5278
Mailing Address - Fax:816-285-5278
Practice Address - Street 1:335 NW BARRY RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64155-2740
Practice Address - Country:US
Practice Address - Phone:816-468-5278
Practice Address - Fax:816-285-5278
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004010062225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO34554027OtherBCBS
MO34554027OtherBCBS