Provider Demographics
NPI:1891744538
Name:AZZAM, SAMIR (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMIR
Middle Name:
Last Name:AZZAM
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 1:1211 W LA PALMA AVE STE 707
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-2814
Mailing Address - Country:US
Mailing Address - Phone:714-776-2100
Mailing Address - Fax:714-776-1960
Practice Address - Street 1:1211 W LA PALMA AVE STE 707
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2814
Practice Address - Country:US
Practice Address - Phone:714-776-2100
Practice Address - Fax:714-776-1960
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51621174400000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A516210Medicaid
CA00A516210Medicaid