Healthcare Provider Details

I. General information

NPI: 1184588873
Provider Name (Legal Business Name): EGOR PAKHOMOV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5617 COTTONTAIL DR
LONGMONT CO
80503-9529
US

IV. Provider business mailing address

5617 COTTONTAIL DR
LONGMONT CO
80503-9529
US

V. Phone/Fax

Practice location:
  • Phone: 510-766-4362
  • Fax:
Mailing address:
  • Phone: 510-766-4362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0938471
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: