Healthcare Provider Details

I. General information

NPI: 1194973065
Provider Name (Legal Business Name): CLAIRE MICHELE AZZAM OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 E MAIN ST.
VENTURA CA
93001
US

IV. Provider business mailing address

828 E MAIN ST.
VENTURA CA
93001
US

V. Phone/Fax

Practice location:
  • Phone: 805-643-5687
  • Fax: 805-643-4175
Mailing address:
  • Phone: 805-643-5687
  • Fax: 805-643-4175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV007271-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT33453TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: