Provider Demographics
NPI:1457046641
Name:AZZAM, EZOZA (DO)
Entity type:Individual
Prefix:
First Name:EZOZA
Middle Name:
Last Name:AZZAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:EZOZA
Other - Middle Name:
Other - Last Name:RAJABALIEV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 980257
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-0257
Mailing Address - Country:US
Mailing Address - Phone:804-828-9783
Mailing Address - Fax:
Practice Address - Street 1:417 N 11TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5024
Practice Address - Country:US
Practice Address - Phone:804-828-0733
Practice Address - Fax:804-828-8300
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1457046641207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology