Provider Demographics
NPI:1760057194
Name:AZEEM, FAZLE (MD)
Entity type:Individual
Prefix:
First Name:FAZLE
Middle Name:
Last Name:AZEEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MD
Other - Middle Name:FAZLE
Other - Last Name:AZEEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40 DORA ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-2107
Mailing Address - Country:US
Mailing Address - Phone:917-202-8684
Mailing Address - Fax:
Practice Address - Street 1:5015 BEACH CHANNEL DR
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-1110
Practice Address - Country:US
Practice Address - Phone:718-734-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2024-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109585-01207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine