Healthcare Provider Details

I. General information

NPI: 1750008041
Provider Name (Legal Business Name): AVICENNA MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 02/17/2023
Certification Date: 02/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2283 S MONACO PKWY STE 105
DENVER CO
80222-5845
US

IV. Provider business mailing address

2283 S MONACO PKWY STE 105
DENVER CO
80222-5845
US

V. Phone/Fax

Practice location:
  • Phone: 720-531-2370
  • Fax: 303-632-6153
Mailing address:
  • Phone: 720-531-2370
  • Fax: 303-632-6153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ALI AKSAR SHAH
Title or Position: MANAGER
Credential: MD
Phone: 580-916-5095