Basic Information
| Provider Information | |||||||||
| NPI: | 1538416698 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AZAM | ||||||||
| FirstName: | FARYAL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 8667954020 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | WELLESLEY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024811711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812637360 | ||||||||
| FaxNumber: | 7812637360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2012 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TPOP63 | FL | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 5452 | MA | N | Eye and Vision Services Providers | Optometrist | 152WC0802X | OEG002637 | PA | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152W00000X | OP1000393 | DC | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.