Provider Demographics
NPI:1689961179
Name:GHAVAM, AHMENEH (MD)
Entity type:Individual
Prefix:
First Name:AHMENEH
Middle Name:
Last Name:GHAVAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 110429
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80042-0429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4090 BRIARGATE PKWY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7815
Practice Address - Country:US
Practice Address - Phone:303-724-8393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361433552080P0203X
CODR.00727202080P0203X
IL036.1433552080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1689961179Medicaid
WIK400140569Medicare PIN