Provider Demographics
NPI:1609217140
Name:FARYAL AZAM OD LLC
Entity Type:Organization
Organization Name:FARYAL AZAM OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FARYAL
Authorized Official - Middle Name:
Authorized Official - Last Name:AZAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:267-241-8006
Mailing Address - Street 1:9475 ROOSEVELT BLVD
Mailing Address - Street 2:INSIDE PEARLE VISION
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-2212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9475 ROOSEVELT BLVD
Practice Address - Street 2:INSIDE PEARLE VISION
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-2212
Practice Address - Country:US
Practice Address - Phone:215-698-7600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002637152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty