Provider Demographics
NPI:1376833129
Name:AVEZBADALOV, AZRIEL (DO)
Entity type:Individual
Prefix:DR
First Name:AZRIEL
Middle Name:
Last Name:AVEZBADALOV
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7850 LAGO DEL MAR DR APT 116
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-4984
Mailing Address - Country:US
Mailing Address - Phone:646-671-9252
Mailing Address - Fax:
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-432-2297
Practice Address - Fax:260-434-6433
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY267039207RC0000X
FLOS13717207RC0000X
OH34.016578207RC0000X
IN02005736A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018825600Medicaid
IN300029932Medicaid
FLPENDINGOtherMEDICARE
IN260690286OtherMEDICARE