Provider Demographics
NPI:1083902431
Name:ALBASHAIREH, DERAR ZAKARYYA SHANWAN (MBBS)
Entity Type:Individual
Prefix:
First Name:DERAR
Middle Name:ZAKARYYA SHANWAN
Last Name:ALBASHAIREH
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 560825
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80256-0825
Mailing Address - Country:US
Mailing Address - Phone:719-595-7580
Mailing Address - Fax:719-545-0176
Practice Address - Street 1:3670 PARKER BLVD STE 101
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2285
Practice Address - Country:US
Practice Address - Phone:719-562-2900
Practice Address - Fax:719-924-1592
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.207044207R00000X
MI4301098836207R00000X
CODR.0060690207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000163537Medicaid