Healthcare Provider Details

I. General information

NPI: 1114457769
Provider Name (Legal Business Name): CRYSTAL NNENNE AZU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 04/15/2025
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL DIV IM CARDIOLOGY, STE 8B
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-1291
  • Fax: 314-362-4278
Mailing address:
  • Phone: 314-362-1291
  • Fax: 314-362-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2024030894
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2024030894
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2024030894
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: