Basic Information
| Provider Information | |||||||||
| NPI: | 1215998349 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AZAR DANESHBOD MD MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 SOUTHWYCK BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Practice Location | |||||||||
| Address1: | 3751 KATELLA AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ALAMITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907203101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5627993132 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 10/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | DANESHBOD | ||||||||
| AuthorizedOfficialFirstName: | AZAR | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5627993132 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | GR0093921 | 05 | CA | MEDICAID | HW14237 | 01 | CA | MEDICARE | OTHER |