Provider Demographics
NPI:1720057318
Name:SOROUSH, AZAM (MD)
Entity Type:Individual
Prefix:
First Name:AZAM
Middle Name:
Last Name:SOROUSH
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 1:61 DAVIS AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-4401
Mailing Address - Country:US
Mailing Address - Phone:732-776-4860
Mailing Address - Fax:732-776-4867
Practice Address - Street 1:61 DAVIS AVE
Practice Address - Street 2:STE 1
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-4401
Practice Address - Country:US
Practice Address - Phone:732-776-4860
Practice Address - Fax:732-776-4867
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA068606002080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7232306Medicaid
NJG2506Medicare UPIN
NJ204708UWHMedicare PIN