Provider Demographics
NPI:1811993454
Name:AZAM, SYED FAROOQ (MD)
Entity type:Individual
Prefix:
First Name:SYED
Middle Name:FAROOQ
Last Name:AZAM
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 1:35400 BOB HOPE DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1772
Mailing Address - Country:US
Mailing Address - Phone:760-202-0686
Mailing Address - Fax:760-770-4563
Practice Address - Street 1:35400 BOB HOPE DR
Practice Address - Street 2:SUITE 210
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-1772
Practice Address - Country:US
Practice Address - Phone:760-202-0686
Practice Address - Fax:760-770-4563
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67791207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A677910Medicaid
CAG62051Medicare UPIN
CA00A677911Medicare ID - Type Unspecified