Healthcare Provider Details

I. General information

NPI: 1871976704
Provider Name (Legal Business Name): ASAL AZIZODDIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2015
Last Update Date: 07/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17284 SLOVER AVE UNIT 204
FONTANA CA
92337-7584
US

IV. Provider business mailing address

17284 SLOVER AVE UNIT 204
FONTANA CA
92337-7584
US

V. Phone/Fax

Practice location:
  • Phone: 909-609-3327
  • Fax:
Mailing address:
  • Phone: 909-609-3327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License Number72439
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: