Provider Demographics
NPI:1902851918
Name:ETEMADI, ALIREZA (MD)
Entity Type:Individual
Prefix:
First Name:ALIREZA
Middle Name:
Last Name:ETEMADI
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 1:100 HEALTH PARK DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-9583
Mailing Address - Country:US
Mailing Address - Phone:303-673-1000
Mailing Address - Fax:
Practice Address - Street 1:100 HEALTH PARK DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-9583
Practice Address - Country:US
Practice Address - Phone:303-673-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67093207Q00000X
CO51266207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G670930Medicaid
CA00G670930OtherBLUE SHIELD
CAG67093OtherSTATE LICENSE #
CO09250255Medicaid
CA00G670930Medicaid
CABL853ZMedicare PIN
CO09250255Medicaid