=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316337868
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IBRAN AZIM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2015
-----------------------------------------------------
Last Update Date | 02/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11550 LEGACY DR STE 470
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75033-1999
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-294-5313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11550 LEGACY DR STE 470
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75033-1999
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-294-5313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------