Provider Demographics
NPI:1760057194
Name:AZEEM, FAZLE (MD)
Entity Type:Individual
Prefix:
First Name:FAZLE
Middle Name:
Last Name:AZEEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MD
Other - Middle Name:FAZLE
Other - Last Name:AZEEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3421 77TH ST APT 308
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-2302
Mailing Address - Country:US
Mailing Address - Phone:917-202-8684
Mailing Address - Fax:
Practice Address - Street 1:275 W MERRICK ROAD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520
Practice Address - Country:US
Practice Address - Phone:516-623-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109585-01207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine