Provider Demographics
NPI:1619980125
Name:AZHAR, EZRA (MD)
Entity Type:Individual
Prefix:
First Name:EZRA
Middle Name:
Last Name:AZHAR
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 1:3415 SW 187TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-3106
Mailing Address - Country:US
Mailing Address - Phone:503-649-5509
Mailing Address - Fax:503-649-7876
Practice Address - Street 1:3415 SW 187TH AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-3106
Practice Address - Country:US
Practice Address - Phone:503-649-5509
Practice Address - Fax:503-649-7876
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14162207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR104604Medicaid
ORR0000BHVGKMedicare ID - Type Unspecified
OR104604Medicaid