Healthcare Provider Details

I. General information

NPI: 1376848960
Provider Name (Legal Business Name): AYAZ AHMED HABIB DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2011
Last Update Date: 06/29/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 4TH SECTION RD SUITE 700
BROCKPORT NY
14420-2414
US

IV. Provider business mailing address

2225 CLINTON AVE S
ROCHESTER NY
14618-2664
US

V. Phone/Fax

Practice location:
  • Phone: 585-473-5051
  • Fax:
Mailing address:
  • Phone: 585-473-5051
  • Fax: 585-473-3033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number6595
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberN006595-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: