Provider Demographics
NPI:1821709775
Name:KHAJEHZADEH, HESHMAT
Entity Type:Individual
Prefix:
First Name:HESHMAT
Middle Name:
Last Name:KHAJEHZADEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9140 W 100TH AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80021-6810
Mailing Address - Country:US
Mailing Address - Phone:720-217-6994
Mailing Address - Fax:
Practice Address - Street 1:9140 W 100TH AVE
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80021-6810
Practice Address - Country:US
Practice Address - Phone:720-217-6994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO834123456Medicaid