Healthcare Provider Details

I. General information

NPI: 1801068382
Provider Name (Legal Business Name): AMIR AKHAVAN AZARI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 WALNUT ST SUIT 920
PHILADELPHIA PA
19107-5109
US

IV. Provider business mailing address

840 WALNUT ST SUITE 920
PHILADELPHIA PA
19107-5109
US

V. Phone/Fax

Practice location:
  • Phone: 215-928-3180
  • Fax:
Mailing address:
  • Phone: 215-928-3180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberMD45090
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: