Provider Demographics
NPI:1639140247
Name:EBADI, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:EBADI
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 1:125 RAMPART WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80230-6406
Mailing Address - Country:US
Mailing Address - Phone:720-858-7600
Mailing Address - Fax:720-858-7610
Practice Address - Street 1:125 RAMPART WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80230-6406
Practice Address - Country:US
Practice Address - Phone:720-858-7600
Practice Address - Fax:720-858-7605
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40389174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO72620544Medicaid
COP00084291Medicare PIN
COC513088Medicare PIN
CO72620544Medicaid