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
StateLicense IDTaxonomies
COCDRH.00540262084E0001X
AL261492084N0400X
CODR.00540262084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084E0001XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyEpilepsy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO00327379Medicaid