Provider Demographics
NPI:1013141951
Name:AZZAM, MOHANNAD FADL (MD)
Entity type:Individual
Prefix:
First Name:MOHANNAD
Middle Name:FADL
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:PO BOX 361585
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35236-1585
Mailing Address - Country:US
Mailing Address - Phone:205-934-4794
Mailing Address - Fax:
Practice Address - Street 1:2052 BLACKRIDGE RD
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-5243
Practice Address - Country:US
Practice Address - Phone:205-934-4794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD30737207R00000X
AL30737208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine