Healthcare Provider Details

I. General information

NPI: 1083640825
Provider Name (Legal Business Name): ADEL BOZORGZADEH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

469 HIGHWAY 50
GILLETTE WY
82718-9330
US

IV. Provider business mailing address

201 W LAKEWAY RD STE 1004
GILLETTE WY
82718-6349
US

V. Phone/Fax

Practice location:
  • Phone: 307-387-9850
  • Fax: 307-387-9890
Mailing address:
  • Phone: 307-387-9850
  • Fax: 307-387-9890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number238379
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberTL8537
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: