Provider Demographics
NPI: | 1437366473 |
---|---|
Name: | ELGAVISH, ROTEM LASZLO ABRAHAM (MD, PHD) |
Entity Type: | Individual |
Prefix: | |
First Name: | ROTEM |
Middle Name: | LASZLO ABRAHAM |
Last Name: | ELGAVISH |
Suffix: | |
Gender: | M |
Credentials: | MD, PHD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 11509 E DORADO AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | ENGLEWOOD |
Mailing Address - State: | CO |
Mailing Address - Zip Code: | 80111-4143 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 10103 RIDGEGATE PKWY STE 125 |
Practice Address - Street 2: | |
Practice Address - City: | LONE TREE |
Practice Address - State: | CO |
Practice Address - Zip Code: | 80124-5525 |
Practice Address - Country: | US |
Practice Address - Phone: | 303-790-8899 |
Practice Address - Fax: | 303-790-2810 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2007-05-17 |
Last Update Date: | 2023-09-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CO | CDRH.0054026 | 2084E0001X |
AL | 26149 | 2084N0400X |
CO | DR.0054026 | 2084N0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No | 2084E0001X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Epilepsy |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CO | 00327379 | Medicaid |