Provider Demographics
NPI:1841489440
Name:AZAD, JACK (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:AZAD
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 1:11900 AVALON BLVD
Mailing Address - Street 2:#100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90061-2867
Mailing Address - Country:US
Mailing Address - Phone:323-756-1317
Mailing Address - Fax:323-756-4015
Practice Address - Street 1:11900 AVALON BLVD
Practice Address - Street 2:#100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90061-2867
Practice Address - Country:US
Practice Address - Phone:323-756-1317
Practice Address - Fax:323-756-4015
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54433208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1891795613OtherGROUP/CORPORATION NPI #
CA0A544334Medicaid
CA1891795613OtherGROUP/CORPORATION NPI #