Healthcare Provider Details

I. General information

NPI: 1922174267
Provider Name (Legal Business Name): ALISHERHON AZAMOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4653 CARMEL MOUNTAIN RD STE 308-201
SAN DIEGO CA
92130-6650
US

IV. Provider business mailing address

7514 GIRARD AVE STE 1124
LA JOLLA CA
92037-5149
US

V. Phone/Fax

Practice location:
  • Phone: 619-955-8494
  • Fax: 619-243-7317
Mailing address:
  • Phone: 619-955-8494
  • Fax: 619-243-7317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberCA761110
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: