=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316905003
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SYED AZIM BUKHARI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2006
-----------------------------------------------------
Last Update Date | 10/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1073 HARDING MEMORIAL PKWY SUITE A
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43302-6363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-383-8579
-----------------------------------------------------
Fax | 740-387-5244
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | L-3549
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43260-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-383-7927
-----------------------------------------------------
Fax | 740-383-7942
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 35042809B
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 35.042809
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------