Healthcare Provider Details

I. General information

NPI: 1538192299
Provider Name (Legal Business Name): MORTEZA KHODAEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3055 ROSLYN ST
DENVER CO
80238-3323
US

IV. Provider business mailing address

PO BOX 110429
AURORA CO
80042-0429
US

V. Phone/Fax

Practice location:
  • Phone: 720-848-9000
  • Fax:
Mailing address:
  • Phone: 303-493-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberDR.0044723
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0044723
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: