Provider Demographics
NPI:1609909423
Name:DATKHAEVA, TATYANA I (MD)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:I
Last Name:DATKHAEVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6825 E TENNESSEE AVE STE 620
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80224-1672
Mailing Address - Country:US
Mailing Address - Phone:720-536-5126
Mailing Address - Fax:303-432-2216
Practice Address - Street 1:6825 E TENNESSEE AVE STE 620
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80224-1672
Practice Address - Country:US
Practice Address - Phone:720-536-5126
Practice Address - Fax:303-432-2216
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45108207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO207Q00000XOtherTAXONOMIES
CO45108 COOtherFAMILY PRACTICE
CO39276813Medicaid
CO39276813Medicaid
CO45108 COOtherFAMILY PRACTICE