Basic Information
Provider Information
NPI: 1003291832
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: AZAR
FirstName: EDWARD
MiddleName: SHIBLI
NamePrefix: DR.
NameSuffix:  
Credential: DPM
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 9675 MONTE VISTA AVE STE E
Address2:  
City: MONTCLAIR
State: CA
PostalCode: 917632213
CountryCode: US
TelephoneNumber: 2135372927
FaxNumber:  
Practice Location
Address1: 9675 MONTE VISTA AVE STE E
Address2:  
City: MONTCLAIR
State: CA
PostalCode: 917632213
CountryCode: US
TelephoneNumber: 2135372927
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/22/2015
LastUpdateDate: 01/06/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 01/06/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
213ES0103XE5241CAY Podiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery

No ID Information.


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