Provider Demographics
NPI:1962501510
Name:MOTAZEDI, MEHDI ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:MEHDI
Middle Name:ROBERT
Last Name:MOTAZEDI
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 1:1985 DOMINION WAY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-1476
Mailing Address - Country:US
Mailing Address - Phone:719-596-4000
Mailing Address - Fax:719-570-6253
Practice Address - Street 1:1985 DOMINION WAY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1476
Practice Address - Country:US
Practice Address - Phone:719-596-4000
Practice Address - Fax:719-570-6253
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27602174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COE25457Medicare UPIN
COC65381Medicare ID - Type Unspecified