Provider Demographics
NPI:1679508337
Name:AZZO, WALID HIKMET (MDPHD)
Entity Type:Individual
Prefix:DR
First Name:WALID
Middle Name:HIKMET
Last Name:AZZO
Suffix:
Gender:M
Credentials:MDPHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1696
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-1696
Mailing Address - Country:US
Mailing Address - Phone:304-324-2725
Mailing Address - Fax:304-324-2780
Practice Address - Street 1:512 CHERRY ST
Practice Address - Street 2:BUILDING I
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-3341
Practice Address - Country:US
Practice Address - Phone:304-324-2725
Practice Address - Fax:304-324-2780
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17728174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0097968000Medicaid
WV1478158OtherUMWA
WV1478158OtherUMWA
WV9327031Medicare PIN
WV0097968000Medicaid
F70516Medicare UPIN
WV0904810001Medicare NSC