Provider Demographics
NPI:1740576271
Name:AZAM, HUMZA SHAHID (DO)
Entity type:Individual
Prefix:
First Name:HUMZA
Middle Name:SHAHID
Last Name:AZAM
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 1:2200 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4364
Mailing Address - Country:US
Mailing Address - Phone:309-665-5755
Mailing Address - Fax:
Practice Address - Street 1:1010 RANCH ROAD 620 S STE 107
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-5638
Practice Address - Country:US
Practice Address - Phone:512-233-4606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL5101019538207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine