Provider Demographics
NPI:1750008041
Name:AVICENNA MEDICAL CLINIC
Entity type:Organization
Organization Name:AVICENNA MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALI
Authorized Official - Middle Name:AKSAR
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-916-5095
Mailing Address - Street 1:2283 S MONACO PKWY STE 105
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80222-5845
Mailing Address - Country:US
Mailing Address - Phone:720-531-2370
Mailing Address - Fax:303-632-6153
Practice Address - Street 1:2283 S MONACO PKWY STE 105
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-5845
Practice Address - Country:US
Practice Address - Phone:720-531-2370
Practice Address - Fax:303-632-6153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-26
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty