Basic Information
| Provider Information | |||||||||
| NPI: | 1811280431 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EGHTEDAR | ||||||||
| FirstName: | ALIREZA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4900 S MONACO ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802373487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7207544800 | ||||||||
| FaxNumber: | 7207544801 | ||||||||
| Practice Location | |||||||||
| Address1: | 1721 E 19TH AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802181258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7207544800 | ||||||||
| FaxNumber: | 7207544801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2011 | ||||||||
| LastUpdateDate: | 07/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 55429 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | 55429 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207P00000X | N9365 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 4301099957 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 78133530 | 05 | CO | MEDICAID |