Provider Demographics
NPI:1891018057
Name:CHARLES J. AZZAM M.D., P.C.
Entity Type:Organization
Organization Name:CHARLES J. AZZAM M.D., P.C.
Other - Org Name:CHARLES J. AZZAM, M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:AZZAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-551-4113
Mailing Address - Street 1:1916 OPITZ BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3304
Mailing Address - Country:US
Mailing Address - Phone:703-551-4113
Mailing Address - Fax:703-491-1019
Practice Address - Street 1:1916 OPITZ BLVD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3304
Practice Address - Country:US
Practice Address - Phone:703-551-4113
Practice Address - Fax:703-491-1019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101041648207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty