Provider Demographics
NPI:1538261235
Name:ESFAHANI, REZA S (DO)
Entity type:Individual
Prefix:
First Name:REZA
Middle Name:S
Last Name:ESFAHANI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12650 W. 64TH AVENUE
Mailing Address - Street 2:UNIT E501
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80004
Mailing Address - Country:US
Mailing Address - Phone:303-431-4127
Mailing Address - Fax:303-431-4553
Practice Address - Street 1:12650 W. 64TH AVENUE
Practice Address - Street 2:UNIT E501
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80004
Practice Address - Country:US
Practice Address - Phone:303-431-4127
Practice Address - Fax:303-431-4553
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36069207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01360692Medicaid
COG61773Medicare UPIN
CO10112Medicare ID - Type Unspecified