Basic Information
| Provider Information | |||||||||
| NPI: | 1376833129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AVEZBADALOV | ||||||||
| FirstName: | AZRIEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6920 POINTE INVERNESS WAY STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604793514 | ||||||||
| FaxNumber: | 2604793520 | ||||||||
| Practice Location | |||||||||
| Address1: | 7950 W JEFFERSON BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604322297 | ||||||||
| FaxNumber: | 2604346433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2011 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | OS13717 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | 72069 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0000X | 02005736A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 300029932 | 05 | IN | MEDICAID | PENDING | 01 | FL | MEDICARE | OTHER | 260690286 | 01 | IN | MEDICARE | OTHER | 018825600 | 05 | FL | MEDICAID |