Provider Demographics
NPI:1811280431
Name:EGHTEDAR, ALIREZA (MD)
Entity type:Individual
Prefix:
First Name:ALIREZA
Middle Name:
Last Name:EGHTEDAR
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 1:4900 S MONACO ST STE 210
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-3487
Mailing Address - Country:US
Mailing Address - Phone:720-754-4800
Mailing Address - Fax:720-754-4801
Practice Address - Street 1:1721 E 19TH AVE STE 300
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1258
Practice Address - Country:US
Practice Address - Phone:720-754-4800
Practice Address - Fax:720-754-4801
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO55429207R00000X, 207RH0003X, 207R00000X
TXN9365207P00000X
MI4301099957207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO78133530Medicaid
CO427049YWUPMedicare PIN
CO78133530Medicaid