Provider Demographics
NPI:1437267663
Name:AGAHTEHRANI, ABDOLREZA (MD)
Entity Type:Individual
Prefix:DR
First Name:ABDOLREZA
Middle Name:
Last Name:AGAHTEHRANI
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:PO BOX 950202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0202
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:6420 DUTCHMANS PKWY
Practice Address - Street 2:STE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3372
Practice Address - Country:US
Practice Address - Phone:502-891-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43033207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000635481OtherANTHEM
KY50031143OtherPASSPORT & PASSPORT ADVTG - NCVA
KY7100045440Medicaid
KYP00893011OtherRAILROAD MEDICARE - NCVA
3737980000OtherPASSPORT ADVANTAGE
KY000000693017OtherANTHEM - NCVA
IN201044560Medicaid
50025829OtherPASSPORT
KY000057058WOtherHUMANA - NCVA
50025829OtherPASSPORT
I60688Medicare UPIN
KYP00893011OtherRAILROAD MEDICARE - NCVA
KY1271856Medicare PIN