Provider Demographics
NPI:1891489787
Name:AZAM, AMINA (OD)
Entity Type:Individual
Prefix:
First Name:AMINA
Middle Name:
Last Name:AZAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 MAPLE AVE E
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4629
Mailing Address - Country:US
Mailing Address - Phone:703-255-1502
Mailing Address - Fax:
Practice Address - Street 1:260 MAPLE AVE E
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4629
Practice Address - Country:US
Practice Address - Phone:703-255-1502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618003269152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist