Provider Demographics
NPI:1689661035
Name:AZZONI, MICHAEL O (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:O
Last Name:AZZONI
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 1:250 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-1396
Mailing Address - Country:US
Mailing Address - Phone:978-632-0383
Mailing Address - Fax:978-632-0714
Practice Address - Street 1:250 GREEN ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-1396
Practice Address - Country:US
Practice Address - Phone:978-632-0383
Practice Address - Fax:978-632-0714
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA151384207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3170837Medicaid
MA3170837Medicaid