Provider Demographics
NPI:1356562805
Name:DOUYON DE AZEVEDO, MARIO (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:DOUYON DE AZEVEDO
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 1:3878 STATE ROUTE 11
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-3726
Mailing Address - Country:US
Mailing Address - Phone:518-483-6566
Mailing Address - Fax:
Practice Address - Street 1:3878 STATE ROUTE 11
Practice Address - Street 2:SUITE 2
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-3726
Practice Address - Country:US
Practice Address - Phone:518-483-6566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223962-1207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01943719Medicaid
NYG90729Medicare UPIN