Provider Demographics
NPI:1922480201
Name:AZAR, MICHELLA (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLA
Middle Name:
Last Name:AZAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 W KIMBERLY RD STE 205
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-3059
Mailing Address - Country:US
Mailing Address - Phone:563-421-0100
Mailing Address - Fax:
Practice Address - Street 1:3200 W KIMBERLY RD STE 205
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-3059
Practice Address - Country:US
Practice Address - Phone:563-421-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-23
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-51416207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001187662OtherANTHEM
IN201301470Medicaid