Provider Demographics
NPI:1508168758
Name:YAVARI, AIDA (DO)
Entity Type:Individual
Prefix:DR
First Name:AIDA
Middle Name:
Last Name:YAVARI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S ROLLIE AVE
Mailing Address - Street 2:BILLING DEPT-CREDENTIALIST
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1508
Mailing Address - Country:US
Mailing Address - Phone:303-286-4560
Mailing Address - Fax:303-286-4589
Practice Address - Street 1:1830 LAPORTE AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-2341
Practice Address - Country:US
Practice Address - Phone:970-416-6240
Practice Address - Fax:970-416-6241
Is Sole Proprietor?:No
Enumeration Date:2010-11-20
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0056108207Q00000X
CA20A11477207Q00000X
FLOS11648207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006244000Medicaid
FLGK275ZMedicare PIN