Healthcare Provider Details

I. General information

NPI: 1376833129
Provider Name (Legal Business Name): AZRIEL AVEZBADALOV D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2011
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 W JEFFERSON BLVD
FORT WAYNE IN
46804-4140
US

IV. Provider business mailing address

7850 LAGO DEL MAR DR APT 116
BOCA RATON FL
33433-4984
US

V. Phone/Fax

Practice location:
  • Phone: 260-432-2297
  • Fax: 260-434-6433
Mailing address:
  • Phone: 646-671-9252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number267039
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberOS13717
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number34.016578
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number02005736A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: