Provider Demographics
NPI:1376508044
Name:AZAD, MANOUCHEHR (MD)
Entity type:Individual
Prefix:DR
First Name:MANOUCHEHR
Middle Name:
Last Name:AZAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MANOUCH
Other - Middle Name:
Other - Last Name:AZAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1700 COFFEE RD
Mailing Address - Street 2:DEPARTMENT OF RADIATION ONCOLOGY
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2803
Mailing Address - Country:US
Mailing Address - Phone:209-572-7237
Mailing Address - Fax:209-526-5280
Practice Address - Street 1:1700 COFFEE RD
Practice Address - Street 2:DEPARTMENT OF RADIATION ONCOLOGY
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2803
Practice Address - Country:US
Practice Address - Phone:209-572-7237
Practice Address - Fax:209-526-5280
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC412502085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C412500Medicaid
CAGR0078260Medicaid
D82125Medicare UPIN
CAGR0078260Medicaid
00C412500Medicare ID - Type UnspecifiedPPIN