Provider Demographics
NPI:1558833434
Name:ALAZZAWI, FARKAD KHALOK
Entity Type:Individual
Prefix:
First Name:FARKAD
Middle Name:KHALOK
Last Name:ALAZZAWI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4744 MOORPARK WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95842-3147
Mailing Address - Country:US
Mailing Address - Phone:916-380-3866
Mailing Address - Fax:
Practice Address - Street 1:4744 MOORPARK WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95842-3147
Practice Address - Country:US
Practice Address - Phone:916-380-3866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1034281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF4746270Medicaid