Provider Demographics
NPI:1457771909
Name:AZURDIA, JACOB (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:AZURDIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1652 UTICA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-1240
Mailing Address - Country:US
Mailing Address - Phone:260-450-2305
Mailing Address - Fax:
Practice Address - Street 1:1652 UTICA ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-1240
Practice Address - Country:US
Practice Address - Phone:260-450-2305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00640582085R0202X
OK323452085R0202X
WYTL65542085R0202X
NE332292085R0202X
NY3153962085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program