Provider Demographics
NPI:1891795613
Name:JACK AZAD,M.D.,INC.
Entity Type:Organization
Organization Name:JACK AZAD,M.D.,INC.
Other - Org Name:TRI-CITY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:AZAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-756-1317
Mailing Address - Street 1:11900 AVALON BLVD
Mailing Address - Street 2:#100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90061-2867
Mailing Address - Country:US
Mailing Address - Phone:323-756-1317
Mailing Address - Fax:323-756-4015
Practice Address - Street 1:11900 AVALON BLVD STE 101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90061-2867
Practice Address - Country:US
Practice Address - Phone:323-756-1317
Practice Address - Fax:323-756-4015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-22
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A544334Medicaid
CA0A544334Medicaid