=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679508337
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WALID HIKMET AZZO MD.PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 10/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 512 CHERRY ST BUILDING I
-----------------------------------------------------
City | BLUEFIELD
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 24701-3341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-324-2725
-----------------------------------------------------
Fax | 304-324-2780
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1696
-----------------------------------------------------
City | BLUEFIELD
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 24701-1696
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-324-2725
-----------------------------------------------------
Fax | 304-324-2780
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 17728
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------