Provider Demographics
NPI:1144227729
Name:ETTEFAGH, KEIVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEIVAN
Middle Name:
Last Name:ETTEFAGH
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 1:2707 HENRY ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-3669
Mailing Address - Country:US
Mailing Address - Phone:336-574-4280
Mailing Address - Fax:336-574-4634
Practice Address - Street 1:2707 HENRY ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405
Practice Address - Country:US
Practice Address - Phone:336-574-4280
Practice Address - Fax:336-574-4634
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD07109208000000X
NC2018-00348208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9002176Medicaid
RI007005294Medicare PIN
RI9002176Medicaid