Provider Demographics
NPI:1295714129
Name:ADHAL, AZZAM A (MD)
Entity type:Individual
Prefix:DR
First Name:AZZAM
Middle Name:A
Last Name:ADHAL
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 15909
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32406-5909
Mailing Address - Country:US
Mailing Address - Phone:850-784-6696
Mailing Address - Fax:850-785-2100
Practice Address - Street 1:2195 JENKS AVE
Practice Address - Street 2:STE B
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4551
Practice Address - Country:US
Practice Address - Phone:850-784-6696
Practice Address - Fax:850-785-2100
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME39261207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL066935100Medicaid
FL0080NOtherFLORIDA BLUE
FL1518360288OtherFLORIDA BLUE
FL1518360288OtherFLORIDA BLUE
FL03604Medicare PIN