Basic Information
| Provider Information | |||||||||
| NPI: | 1457771909 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AZURDIA | ||||||||
| FirstName: | JACOB | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2008 CARIBOU DR | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805254325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704844757 | ||||||||
| FaxNumber: | 9704844759 | ||||||||
| Practice Location | |||||||||
| Address1: | 1024 S LEMAY AVE | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805243929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704957000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2014 | ||||||||
| LastUpdateDate: | 07/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 32345 | OK | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | TL6554 | WY | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 33229 | NE | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | DR.0064058 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.