Healthcare Provider Details

I. General information

NPI: 1144210642
Provider Name (Legal Business Name): GORDON JEROME AZAR JR. M.D., F.A.C.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 NORTHSIDE CHEROKEE BLVD STE 150
CANTON GA
30115-8018
US

IV. Provider business mailing address

460 NORTHSIDE CHEROKEE BLVD STE 150
CANTON GA
30115-8018
US

V. Phone/Fax

Practice location:
  • Phone: 470-639-6250
  • Fax: 770-345-0712
Mailing address:
  • Phone: 470-639-6250
  • Fax: 770-345-0712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number31380
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: