Healthcare Provider Details

I. General information

NPI: 1558757997
Provider Name (Legal Business Name): KRISTOPHER AZEVEDO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 HAMRICK RD
CENTRAL POINT OR
97502-3072
US

IV. Provider business mailing address

931 CHEVY WAY
MEDFORD OR
97504-4127
US

V. Phone/Fax

Practice location:
  • Phone: 541-690-3600
  • Fax: 541-664-3735
Mailing address:
  • Phone: 541-690-3555
  • Fax: 541-842-2212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD179559
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: