Healthcare Provider Details

I. General information

NPI: 1508168758
Provider Name (Legal Business Name): AIDA YAVARI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2010
Last Update Date: 05/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 LAPORTE AVE
FORT COLLINS CO
80521-2341
US

IV. Provider business mailing address

203 S ROLLIE AVE BILLING DEPT-CREDENTIALIST
FORT LUPTON CO
80621-1508
US

V. Phone/Fax

Practice location:
  • Phone: 970-416-6240
  • Fax: 970-416-6241
Mailing address:
  • Phone: 303-286-4560
  • Fax: 303-286-4589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0056108
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A11477
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS11648
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: