Provider Demographics
NPI:1639517881
Name:ENTEZARI, PEGAH (MD)
Entity Type:Individual
Prefix:DR
First Name:PEGAH
Middle Name:
Last Name:ENTEZARI
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 1:2355 HWY 36 W.
Mailing Address - Street 2:STE. 100
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-3905
Mailing Address - Country:US
Mailing Address - Phone:651-336-5587
Mailing Address - Fax:
Practice Address - Street 1:2355 HWY 36 W.
Practice Address - Street 2:STE. 100
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-3905
Practice Address - Country:US
Practice Address - Phone:651-336-5587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-10
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN694992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1639517881Medicaid