Healthcare Provider Details

I. General information

NPI: 1619364783
Provider Name (Legal Business Name): VITALI AZOUZ M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2015
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 FOREST LN BLDG C
DALLAS TX
75230-2571
US

IV. Provider business mailing address

7777 FOREST LN BLDG C
DALLAS TX
75230-2571
US

V. Phone/Fax

Practice location:
  • Phone: 972-702-8888
  • Fax:
Mailing address:
  • Phone: 972-702-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberU1231
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: