Healthcare Provider Details

I. General information

NPI: 1083636930
Provider Name (Legal Business Name): DEEPAK G. AZAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 CHARLEVOIX CT
FLOYDS KNOBS IN
47119-9761
US

IV. Provider business mailing address

3505 CHARLEVOIX CT
FLOYDS KNOBS IN
47119-9761
US

V. Phone/Fax

Practice location:
  • Phone: 502-216-2900
  • Fax:
Mailing address:
  • Phone: 502-216-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number01043333
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35511
License Number StateKY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier64880099
Identifier TypeMEDICAID
Identifier StateKY
Identifier Issuer
# 2
Identifier200028800B
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: