Provider Demographics
NPI:1902855513
Name:KOOCHEK, KEYVAN (MD)
Entity Type:Individual
Prefix:
First Name:KEYVAN
Middle Name:
Last Name:KOOCHEK
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 1:2075 S COTTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-3040
Mailing Address - Country:US
Mailing Address - Phone:480-718-0568
Mailing Address - Fax:480-307-6676
Practice Address - Street 1:11000 N SCOTTSDALE RD
Practice Address - Street 2:STE 120
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-6130
Practice Address - Country:US
Practice Address - Phone:480-455-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34947207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ108994Medicaid
AZZ120345Medicare PIN
AZ108994Medicaid
AZZ147166Medicare PIN